I imagine most people not familiar with Africa would be hesitant about taking a bus across borders. When calling the number I pulled of a website that seem developed in the 90’s and bought a ticket for a 6 hour drive from Nairobi (Kenya) to Arusha (Tanzania), that hesitation was not exactly quelled.
However, what arrived at 8 am in front of my hotel was a 28 seat bus comfortable enough that I slept for half the journey, and admired the beautiful countryside for the rest. So far my first time in Tanzania was going surprisingly smooth and the country seemed a pleasant place to visit. I didn’t know yet that the stories I was going to hear during the next few days would show me a very different reality.
I had come to Arusha to join the RCSI research team responsible for coordinating SURG-Africa, a four year global surgery project operating in Zambia, Malawi, and Tanzania. In all honesty I didn’t know much about the program before my arrival. I didn’t even know what my job would entail as an intern. I had read a few papers published by the team and had a handful of logistical phone calls with the RCSI programme director, Dr. Jakub Gajewski, or Kuba as he likes to be known, but nothing that gave me a solid background for what awaited me when I arrived. I learned a lot over dinner with the team that first night.
SURG-Africa has worked to create partnerships between surgical specialists from local urban hospitals with clinicians and surgeons in rural districts. These surgical specialists travel to district hospitals to train and mentor surgical teams which include medical doctors, assistant medical officers (non-doctors), anaesthesia providers (mostly nurses) and general nurses who happen to be attached to the operating theater department. The goal is to increase their capabilities to provide safe surgery and reduce mortality (which can often occur when patients are in transport to referral hospitals that can be as far as 160km away). The RCSI team, along with their partners from Oxford, were in Arusha for a two day meeting to discuss the project’s progress within Tanzania. Those two days, for me, shed light on the sheer complexity of global surgery.
The meeting started about 2 hours late. The district hospitals presented their activities over the past year. With every presentation I got a growing sense that SURG-Africa really has been making a positive impact. Every district surgeon who spoke noted clear improvements in their surgical capacity, a decrease in patient referrals to other hospitals, increases in revenue, and in some cases even an increase in hospital staff morale, going beyond its on paper mission of just surgical training.
The best example I have of this is a story told by one of the district hospitals about their ‘new’ anesthesia machine. On one of the visits, their specialist noted the machine sitting in the corner of the operating theatre. It had simply lay there dormant for a decade because either no one realized what it was, or no one had been trained in how to use it. The specialist was able to teach the medical staff how to apply it, and such a simple thing has made a significant change in their day to day cases.
This unawareness was not ignorance nor a lack of skill the district surgeons (or surgical providers as one may say) possess in surgery. Rather, it is a reality of how they were trained and how surgery is conducted in some of these hospitals. Much discourse in global surgery seems to surround the importance of high quality surgeons, but the surgeons I met in Arusha are highly skilled, driven, and friendly. They work in conditions that I believe most ‘western’ doctors would have a hard time performing in, because the equipment around them is scarcer and less advanced. Even the specialists from the same country were shocked at the conditions inside some of these district hospitals, and commented on how a lack of equipment hinders their ability to proceed with a tutorial surgery. This plays into what the story revealed as the paramount issue: this hospital is fortunate to have an anesthesia machine. Many don’t, and this is only one of the many pieces of equipment that are scarce.
With each presentation from the districts the list of missing equipment grew and ranged from the niche, affiliated with specialized surgeries, to the most basic essentials like drapes, sutures, and linens. Without fail, every single district surgeon listed missing equipment as a difficulty, and some even went as far to ask what SURG-Africa could do to help.
After hearing these pleas my gut reaction was to run to my boss and ask how can we help provide the required equipment. Here I was met with one of the main complexities: we should not be the ones to provide the equipment. Kuba explained that previous interventions have aimed to act as substitutes for what is missing within a country, but often that weakens the underlying government structure. They are short term solutions that may turn into long term problems. With the global shift to sustainable practices and projects, the aim needs to be strengthening internal structures so they can run on their own.
I knew all these points were logical, but I couldn’t help but feel like we were letting the surgeons in the room down. Many of the surgeons were naturally disheartened and unsatisfied with the pragmaticism that didn’t solve their problem. That was until Dr. Kondo talked. A soft spoken man, Dr. Kondo is one of the chief researchers for SURG-Africa in Tanzania, and the head surgeon in Kilimanjaro Christian Medical Centre. He clearly held the respect of everyone in the room. I wish I had written his direct quote, because it was responded to with nods and murmurs of appreciation for a comment which seemed to give an answer. But in its essence, Kondo pointed out that a lack of equipment does not stop SURG-Africa from being productive. Having an incomplete checklist of equipment did not mean that no tutolage could be given and no surgery could be performed. Surgeons had to focus on how to best use the resources around them to give the best care possible, because the equipment available was the district surgeons daily reality. Patients still required surgery no matter the inventory. It’s making the best of a bad situation, which needs to be done in the absence of all the necessary infrastructure. Still, it’s much easier said than done.
Getting on the bus five days later was a much different experience, for after reflection it’s easy to make such a journey safely. The driver makes the trip twice a day, the roads were paved within the last 10 years, and if requested, the bus can drop you off to a specific location. However, all the infrastructure is there, and established, the same cannot be fully said for these hospitals. I left Arusha content that SURG-Africa so far has been working beautifully, but not ecstatic at the future of global surgery. In my opinion SURG-Africa is an eloquent model for rural surgical capacity building. It opens up internal communication, uses local sustainable mentorship, and its challenge in the next few years will be convincing governments to adopt it. However, rural surgical capacity will always be limited if the lack of basic equipment and infrastructure are left unresolved.
The project is funded by the European Union’s Horizon 2020 Programme (Grant Agreement no. 733391) SURG-Africa is a collaboration between: Royal College of Surgeons in Ireland, Tanzania Surgical Association, University of Malawi (College of Medicine), Surgical Society of Zambia, Radboud University Medical Centre (Netherlands), University of Oxford (UK), East Central and Southern African-Health Community (ECSA-HC), College of Surgeons of East Central and Southern Africa (COSECSA), and Ministries of Health in Malawi, Tanzania and Zambia.