Erica Frenkel

Director, Business Strategy, UAM Global

This conversation is closed.

How do we make safe surgery part of the global health agenda?

Excluded from the Millennium Development Goals and most funders’ priorities, surgical and postoperative care is desperately lacking across health systems in low-income countries, as I discuss in my TED talk. In a 2008 article, Drs. Paul Farmer and Jim Kim state this problem bluntly: “surgery may be thought to be the neglected stepchild of global public health”.
Research shows that the need is great and growing throughout the developing world with increased incidence of road accidents, infrastructure-related injuries and non-communicable diseases such as cancers, diabetes and cardio-vascular diseases.

So why has surgery been so overlooked as a public health priority? How do we make safe surgery part of the global health agenda? What does it mean to improve access as well as safety? What players need to be involved in these efforts?

This Live Conversation will start on Feb. 23, 2012, 1:00pm EST/ 10:00am PST

Closing Statement from Erica Frenkel

Thank everyone for a good conversation. Perhaps not surprisingly more questions were raised than were answered. Some of the salient points were raised though - is it cost-prohibitive to offer safe surgery? How do you train enough people to carry out all the roles related to surgery? How do you measure outcomes? Whose responsibility is it?

I would welcome the chance to follow up with anyone. Please feel free to email me on my profile page on

Here's to safe surgery (and anesthesia!) everywhere, for everyone!

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    Feb 23 2012: Team approaches in the OR and beyond the hospital improve surgery safety. Does this conversation and commitment begin with surgeons and their teams? Can there be bottom up approaches?
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      Feb 23 2012: This is critical- not just internationally, but everywhere. We don't currently have teams in the OR. Imagine eleven football players showing up at the stadium to play a game and they are just meeting each other. That's what we currently do. I was Chief of Surgery at a University, but I quit so we can start a new model based on a bottom-up team approach. Loving our patients and being humble is the key to patient safety (got this from Peter Pronovost, but it is exactly what we are doing and teaching at our new academic medical center).
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        Feb 23 2012: Bruce, I'd love to hear more about the "bottom up approach" and how you were able to get funding/support internally and externally. Do you think yours is a model that would work internationally?
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          Feb 23 2012: Sorry for the delayed response- I was boarding a plane. I think it will work anywhere- construct a group of passionate people around a patient problem (our group that is farthest along is constructed around hernia disease). The group includes patients and family members and evolves into a care community. I wish I could say we have had great support, but it has not been easy- this model goes against all established organizations that have benefited from the status quo fee for service model and hierarchy and vertical department silo approach. We are now in a start-up academic medical center and have only raised some initial seed funding. But, we do have some partnerships (with a local hospital, surgeon practice group and community college) and a funded surgery residency program starting this July.
          It is interesting that we can do a more efficient job of fixing hernias at a Mission in the Dominican Republic than we can in a hospital in the US.
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        Feb 23 2012: Yes, I attended a lecture with Dr. Provonots (I'm a med student) and he talks about the power of informal authority to spur change. Simple checklists save lives and empower everyone to pay close attention. Many thanks for responding.
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      Feb 23 2012: Kathering, you make a great point - that safe surgery is not confined to the OR. I would think all actors - obvious and not obvious - would need to be involved this conversations. Naturally surgeons and their teams need to perform the surgery itself, but if we think about before and after an event in addition to during, there are a host of opportunities to strengthen the team approach that would need to begin with a strong health system. I'm thinking about referral systems and transportation to permitting timely surgery, intake/triage plans at the hospital to help prioritize patients, perioperative and recovery support/infrastructure, among many others.
  • Feb 23 2012: Great thread. I just recently led a short term medical mission trip to Pokhara, Nepal where we dealt with this exact issue. My mentor is doing his PhD around this idea at our university. We'd really like to follow up with you after this conversation ends!
  • Feb 23 2012: I know I already posted, but I think it's helpful to mention that we shouldn't try and replicate exact models of surgical procedures done in developed worlds in countries like Afghanistan or Somalia. Physicians, both out of necessity and ingenuity, have cut corners to ensure that all patients are taken care of and in a cost-effective way. Trust is key.
  • Feb 23 2012: Isn't financing a bigger challenge in developing countries ?.. Without adequate financing sources, surgery cannot be a choice for ailing patients
  • Feb 23 2012: The safety of surgery depends on a host of factors. For example, in Bangladesh, there is a rise in C-section childbirth among middle class and poor alike to avoid the pain and sufferings of natural childbirth. This social phenomenon has increased the number of surgeries.
    With the increase of the surgery came the need for hygienic products such as soap. Many businesses now attempt to profit from these demands. This is an example of economic factor.
    There is a stigma associated with the nurses in Bangladesh. Their “bridal” value tends to be low because they do “dirty” work with the “strangers.” This societal stigma puts additional burden and stress on the doctors who perform surgeries.
    How can we address these factors to improve the safety of the surgery in the developing world?
  • Feb 23 2012: Thank-you for bringing this issue to attention. I am a surgeon in Wazir Akbar Khan hospital in Kabul, Afghanistan. Our greatest hurdle has been finding people with the medical, linguistic, cultural and local expertise who can survey our hospitals, assess what our needs are and relay that to health organizations, NGOs, global health initiatives and foreign donor states.

    Unfortunately, priorities of foreign governments are constantly shifting, and in the case of Afghanistan, the US is primarily focused on the war effort.
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    Feb 23 2012: So let's take this thread in a different direction a little. My company has chosen to approach the need for safer surgery and perioperative care by working on infrastructure and pursuing partnerships with organizations that can leverage the impact of our machine and address other areas that need to be strengthened along the cotinuum of safe surgery. What are some of the areas that you all are working in to strengthen surgical care around the world? Have you been able to quantify (or qualify) an impact of your work? What would you have needed to increase that impact?
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      Feb 23 2012: No doubt, infrastructure is important but I believe that more than that what we require is behavioral and attitudinal change among healthcare providers towards safety and that requires training, monitoring and reinforcement.
  • Feb 23 2012: dear KE, hope it does at some in high time it focused on approach of pre op and post op care, after a point, esp for planned ops( and the point depends upon the surgeon and the hospital policy, which at times, the surgeon does not heed, for good or other reasons)...can only IMPROVE , but unless the surgical skills of that particular surgeon is accountable , results will suffer.
    One can always and should have SOPS in place, worthwhile clinical audits, mortality and morbidity meetings......but who, exactly, is commenting critically on my operating skills? Other than myself, that is , and i am biased.
  • Feb 23 2012: Hello, would surgery not be an expensive form of intervention in the field of global health, particularly in low resource settings? I am suggesting this avenue of thought as a response to your question in the initial post of "why has surgery been so overlooked as a public health priority?"

    BSc Global Health, ICL.
    • Feb 23 2012: Krishna: it's a compelling question given the traditional focus of global health policy on infectious disease. I would argue that access to safe perioperative care is an extension of primary care, especially when looking at emergency surgery. In this space most attention has been directed to maternal mortality, a significant portion of which comes from lack of intervention for post-partum hemmorhage. Other high mortality events such as trauma from accidents and violence could be addressed in part by expanding basic surgical capacity to district and regional hospitals. Establishing surgical capability is expensive, as you point out, but should have a role in public health policy.
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      Feb 23 2012: I would also add that there is a cost to setting up and strengthening surgical care but there is a significant cost (some would argue much greater) to having a population (and productive workforce) that is incapacitated by injuries or conditions that would otherwise be surgically treatable permitting them to contribute more to society. You can see some of the work that some researchers are trying to do on this issue here:
  • Feb 23 2012: Like the term "non-communicable diseases". How long/how much does it take to grow a surgeon, especially a good one? Is it a global issue or a local one?
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      Feb 23 2012: I don't think there is a single answer for this question. The issue you bring up of training surgical staff is one that we keep coming back to. One of the ways some countries deal with this challenge is "task shifting". That is, training more people at lower levels to conduct specific health-related work but perhaps not at the level of a medical doctor. Training for these positions is much less time-consuming and expensive and so can work. Here is an interesting module of the topic:

      With regards to the local vs. global issue, I think there are very few issues that are truly local any more. But it is a heated issue - whose "responsibility" is it to ensure that everyone is cared for and treated when they need it? If the government of a given country can't afford to provide adequate care/treatment, does it fall to those countries that can to provide it? Is there a third way that collaborates and works to bring all governments to a place where they can provide care and treatment for their population?
  • Feb 23 2012: hi. only saw the first one. i hope my answer is still relevant. i would suggest combining the three fields of tourism, education and health care. meaning establishing a med school that offers certain classes in "affordable medicine" for western students. ideally the teaching hospital will be placed near a "tourist resort"/big city. thus offering affordable medicine (as possible) for all involved. such projects will have research in that field grow, which would eventually make projects in other areas more likely to be realized.
    i don't have the proper back round, so my terminology may be off.
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    Feb 23 2012: Though Surgery is not included in MDG, but this is certainly an issue being addressed by WHO, JCI, World Alliance for Patient Safety and others. Surgical safety checklist is one of the tools which could minimize negligence. Improvement of Hand hygiene practices and rationale use of antibiotics are another areas which require adequate address to keep post operative complications to its minimum
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      Feb 23 2012: Agreed. I think the GIEESC (WHO) and other organizations are beginning to recognize the need to improve safety in surgery. With this has come an awareness of the lack of data we have on the issue that can inform policymakers and funders as they determine their priorities going forward. I wonder how we can translate efforts by WHO, JCI and World Alliance for Patient Safety that you mention into improved surgical outcomes and support for training and infrastructure development (among other areas in the field of surgery).
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        Feb 23 2012: The very reason that these programs have not yet showed the outcome is the lack of safety culture. Today itself we were talking in our department that the use of laptops and mobile phones in OR are not acceptable and must be stopped. So yes it requires training to inculcate safety culture and change the mindset of surgeons, anesthetists and others if we want to improve the outcomes. And to improve the infrastructure and training for behavioral change, I believe a top down but participatory approach would be better to start with than a bottom up approach. The global funders must strengthen the Patient Safety movement for development of infrastructure and training. Beside this WHO's Health Promoting Hospital initiative can also contribute in reducing the post operative complications, ALS and consequent cost.
  • Feb 23 2012: How does one even begin to quantify quality in surgery/
  • Feb 23 2012: Firstly develop point of access protocols for safety,,surgical procedural checklists (a with flight safety) for all parts of sxs
    Personnel: team Surgeons and diagnostic staff with paraprofessionals such as Physicians assistants/Nurse practitioners
    and other teams Use the ORS on a Networked Team based Project Management schedules rather than fiefdoms

    HiTech E-Records with great encryption but use open sourced software development
    Since you get wired the stats begin to show up more locally
    One can use them for Local PR campaings and provide more awareness safety and prevention campaigns.
    This can begin to push the safety issues on the roads the equipment and its use and law and enforcement.
    Also for industrial accidents and labour issues the awareness will also rise due to more local exposure. .
  • Feb 23 2012: judging another surgeon is not easy-for various reasons. how do you propose to standardise?
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    Feb 23 2012: Hi everyone, I'm hoping we can get a good conversation going about your thoughts on the state of surgery in resource-constrained environments and how we might improve access to and quality of surgery in these areas. I'd especially love to hear about your experiences with successful and unsuccessful attempts to bring this issue to the fore of global health funders'/practitioners' priorities.