When There’s a Will There’s a Way: Building Surgical Capacity in Uganda

NAME: Katherine Albutt

PROGRAM: General Surgery

PGY: Research Resident (currently completing second year of research)  

Historically, surgery has been largely omitted from the global public health discourse. However, conditions ranging from injuries to cancer to complications from childbirth comprise a significant and growing proportion of the burden of disease, and all require surgical attention. In 2015, the Lancet Commission on Global Surgery (LCoGS) published its finding on the state of surgery across the globe. In its findings, the Commission recommended all countries collect 6 indicators as measures of the strength of their national surgical system. Currently no nationwide, high quality data exists for these indicators in Uganda.

Over the past 18 months, I have been working on is designed to ascertain and improve surgical capacity in Uganda through collection of these metrics at randomly selected hospitals. Specifically, the project seeks to determine the capability, operative volume and post-operative mortality at the district, regional, and national level; evaluate the surgical system; and identify priority areas for system improvement, as determined by local stakeholders. Data collection was completed at 33 representative hospitals around Uganda, including public, private, and not-for-profit hospitals around the country.

The results speak for themselves. The state of surgical affairs in Uganda is dire. The Ugandan public hospital system does not meet LCoGS targets for surgical access, workforce, or volume. On average, less than 25% of population has access to a surgically-capable facility within 2 hours. There are only 0.3 specialist surgical, anesthesiology, and obstetrician providers per 100,000 population nationwide. Despite extreme infrastructural and supply constraints, surgical workforce is the critical driver of operative volume. The nationwide operative volume is only 144.5 operations / 100,000 people / year.

Challenges in surgical care delivery in Uganda can be broadly grouped into preparedness and policy, service delivery, and the financial burden of surgical care: (1) there are significant delays in accessing surgical care, compounded by a malfunctioning referral system; (2) operative capacity is limited by inadequate infrastructure and overwhelmed by emergency and obstetric volume; (3) there are critical workforce shortages, especially amongst specialists; (4) supply chain difficulties are rampant pertaining to essential medications, equipment, supplies, and blood; and (5) patients and families experience significant, variable, and sometimes catastrophic expenditures for surgical care.

Despite these challenges, Ugandan surgeons are amongst the most innovative people I have ever met. Speaking of chest tubes, one surgeon told me: “No, we don’t have chest tubes, we improvise. Actually, in Uganda, in the places I have worked, I have not seen chest tubes. I have only seen them in the textbooks.” Elsewhere, another surgeon stated: “Chest tubes. We actually improvise most of the time. I’m sure if you checked very carefully you might find one or two but most times we improvise. We use whatever is available. Whatever you have.” It is not surprising, then, that the chest tube drainage system is also improvised as a pleurevac would be impossible to find. But they figure it out and they manage to drain the thoracic cavity, albeit perhaps not always in the most optimal or most sterile way. But nonetheless, they almost always find a way.

It is abundantly clear that critical policy and programmatic developments are essential to build surgical capacity and facilitate provision of safe, timely, and affordable surgical care. I hope that the discussions I have had and will continue to have over the coming months and years will lay pave some solid ground for the long road ahead in building surgical capacity in this magnificent country.

Interventional Cardiology Training in Tanzania: Challenges and Rewards

Mazen Albaghdadi, MD MSc

Graduate Assistant, Interventional Cardiology

Fellow, Vascular Medicine and Intervention

Massachusetts General Hospital

PGY9

Interventional Cardiology Training in Tanzania: Challenges and Rewards

Cath Lab Team

The cath lab team at the JKCI was very excited to schedule the many complex cases during my visit that they have been collecting over the past months. Each day, thus far, we have been working until around 8 or 9pm to perform elective complex cases that have been scheduled for this training visit as well as incorporating urgent and semi-urgent (ie, acute coronary syndrome, pre-cardiac surgery cases, etc.) into the schedule.  

The logistics of operating a cath lab are very challenging and require coordination between referring providers and interventional physicians to determine procedural appropriateness and timing, cath lab nurses and administrators to coordinate peri-procedural admission/in-hospital/discharge logistics between home and medical floors, cath lab managers to determine insurance coverage/financial issues, etc. The planning and follow up for a procedure can be more complex than the procedure itself. Cath lab operations are, I would posit, an art and a science, and a craft that has by no means been absolutely mastered to a Zen-like level of autonomous functioning by the 3+ different cath labs I have experienced back home in the States. It goes without saying that the ambitious effort to develop de novo catheterization services in Tanzania by the JKCI and Madaktari (the NGO that I am volunteering with here: https://www.madaktari.org) is not immune to these challenges.

Accordingly it has been difficult to maintain a consistent 8AM start time in the cath lab here at the JKCI but progress is being made. I have recommended a few suggestions including having the general cardiology fellow take responsibility for the cath lab schedule the day prior and then having the entire cath lab team “run the list” the morning of the procedures to determine appropriateness, triage of case order, etc. We have attempted to implement these recommendations and the lab has been very receptive.

After several long days in the cath lab and rounding on patients before and after procedures, a few cases standout. A 36yo male patient with a recent inferior MI who had a residual (sub)total occlusion of the LAD that we were able to recanalize successfully with the use of over 50mm of drug-eluting stents.

Before revasularization

After stent placement

Our chief cath lab technologist and supply manager went to great lengths to ensure we had the appropriate equipment including literally running back and forth between the cath lab and the central supply to obtain the necessary stents (another logistical issue that needs resolution). A 20 yo male patient with a ventricular septal defect (VSD) who needed to undergo right heart catheterization but team hadn’t performed this procedure for over a year and were concerned about placing a 7F sheath into the relatively small statured man; he was ultimately found to have significant left to right ventricular shunting (almost 5:1) and warrants closure (percutaneous vs surgical tbd). Another 40yof with end stage rheumatic heart disease (RHD) in cardiogenic shock with cardiac cirrhosis, renal failure, and pulmonary hypertension. She did not have any cardiac cath procedures but I encountered her in the ICU after rounding on some of our post-percutaneous coronary intervention patients. She had marked abdominal ascites and was in severe respiratory distress, and I recommended a paracentesis. She had previously had multiple paracenteses over the past few weeks, which were performed using an angiocath needle (usually used for IV placement) but it was clear that her ascites was becoming refractory in the setting of inoperable RHD and decompensated heart failure. However placement of a traditional peritoneal drain (generally only performed for refractory ascites for palliative purposes) was not possible as there are no formal paracentesis kits in the hospital. A visiting Chinese ICU physician recommended placing a central line into the peritoneal space which he did successfully and allowed for gradual/safer removal of her ascites without repeat abdominal puncture over the course of the following several days with improvement in her shortness of breath.

Working with my Tanzanian and international colleagues and caring for the incredibly gracious patients with a surprising degree of advanced atherosclerotic and non-atherosclerotic CVD has been eye-opening and amazingly rewarding. I hope the benefit has been mutual and look forward to my return visit.

Developing Cardiovascular Care in Tanzania

Mazen Albaghdadi, MD MSc

Graduate Assistant, Interventional Cardiology

Fellow, Vascular Medicine and Intervention

Massachusetts General Hospital

PGY9

Developing Cardiovascular Care in Tanzania

I was delighted to return to the Jakaya Kikwete Cardiovascular Institute (JKCI) at the Muhumbili University of Health and Allied Sciences in Dar es Salaam, Tanzania. It’s been a year since I last visited and I was eager to see the progress that has been made in the cardiac cath lab where I spent most of my efforts training local cardiologists in the techniques of interventional cardiology.  After arriving, I reviewed with my local colleagues 2 cases of ST-segment elevation myocardial infarction (STEMI) that had been treated the day before my arrival at the JKCI. I was impressed by their ability to technically and logistically manage the care of these complex and severely ill patients. Equally impressive, was the evolution of a referral network that transferred in these patients to the JKCI from surrounding clinics and hospital. This network has steadily been evolving since my last visit, and requires the concerted efforts of administrators, clinicians, and most importantly the trust of patients and the community.

Division of Cardiology Weekly Meeting

Based on our discussion of the STEMI cases, I was asked to share a case. I had the opportunity to present a case at the Division of Cardiology weekly meeting. It was excellent experience, but unique in that I was flanked by pharmaceutical industry banners….a new experience in my short and non-illustrious academic career!