Interview to Professor Ruairí Brugha
Head of Department of Epidemiology and Public Health Medicine, RCSI
SURG-Africa Principal Investigator
Head of Department of Epidemiology and Public Health Medicine, RCSI
SURG-Africa Principal Investigator
How did you start your career, your work in this field?
It actually started almost 40 years ago. I first went out to work in Africa, in Ghana, back in 1983, I was a young doctor, three years qualified, and I found myself working in district hospitals. I worked in three different district hospitals in Ghana, also in Zimbabwe, for about six years over a ten-year period from the early 80’s through to the early 90’s.
When I first got out there while I knew I would need to do surgery I was not properly trained for it, so it was a bit of baptism of fire, really. I was trained. I had a surgeon specialist working with me who did train me in how to do surgery and the people I was serving were getting the best available care but I knew I didn´t want to be a surgeon so I specialized in public health.
I started to do research and before I left Ghana in 1992 I had done some major research in the area of public health, that was what formed my career then for the next 15 years. I worked in the London School of Hygiene and Tropical Medicine for 10 years and then I came back to the RCSI in Ireland. I was doing a research on HIV and AIDS, Tb, malaria, all really important issues at the time.
It was only in 2010 when a colleague from the COSECSA collaboration in RCSI came and had a chat with me. I had already been involved setting up the proposal funded for this collaboration to support training in Africa. But my colleague came and suggested maybe we could do some research in the area of non-physician clinicians doing surgery. And when I worked in Africa 25 years previously I had seen that these Clinical Officers knew about surgery than I as a doctor knew. So that is how the whole thing started.
Why did you decide to go to Africa? What moved you to take such a big step?
I think that what going to Africa gave me was an opportunity to find out what I wanted to do but also an opportunity to do something I felt it was very important. I wanted to do something useful as a doctor and I asked myself, where am I going to find a greater need than in Africa.
When I was working in Africa I was doing surgery, I was taking care of the patients what I realized was the huge amount of ill/health, the problems out there in the population only a little bit of what was coming into us into the hospitals and that was what motivated me as a doctor so I got very much population health focused, caring about the wider population. That was my motivation and I felt Africa was the place to really develop that where the need was. That enabled me to find the direction in my career.
You were in Africa working together with non-physicians Clinical Officers and now you are involved with them through SURG-Africa. Your experience helps you to understand that non-physicians can operate but how other doctors in Ireland see this?
I have to turn the question a little bit and say that one of the biggest challenges was convincing surgeons in Africa of the value and ethics of training Clinical Officers for surgery.
Our first project was COST-Africa in 2011. We ran that in Malawi and Zambia and we were invited in by national surgeons in these two countries who just saw the crying need in rural areas. But I remember making a presentation in 2011 in London to a much broader range of surgeons and I could see some of the scepticism in their faces. However, the reality is that a lot of the surgeons in Africa never leave the cities, they actually don’t know the realities in the rural areas and one of the really positive spin-offs of COST-Africa and now SURG-Africa, is that we are enabling the specialist surgeons to leave the cities where the specialist hospitals are and go out into the rural areas and see the need so I think we are beginning to make that case.
This model is not for every country and some countries believe that they don’t need to train non-physician clinicians to do surgery. We believe that if it is a choice between no surgery being available to people in rural populations or having somebody who has gone through a good training programme, under my experience, they can actually do the surgery better than a general medical officer like I was when I went out. I believe it is an ethical, in fact it is a duty, to provide that service. But we do have to be careful about what these Clinical Officers are allowed to and what they are not allowed to.
Global Surgery is a big concern nowadays, how do you think your work in SURG-Africa is influencing or contributing to it?
What we are doing in SURG-Africa is we are getting down to the district level, down to the rural populations. Nobody has done that and systematically and rigorously researched it the way we are doing. There is a whole sort of agenda, health system agenda, research agenda, that was published in The Lancet Commission on Global Surgery back in 2015. We are the ones implementing it right down at that community level in the rural areas and that is what is unique about SURG-Africa. We are actually reaching the population level. If you only focus on what is happening in the cities in the big specialist hospitals, you are not meeting that neglected rural population.
Could you give me some example of a real impact SURG-Africa can bring to the community?
We are starting off, It is still early days. We could look at it in terms of what kind of research studies we have done, and I think that is important. There is this one study that we have done in Malawi where we have compared outcomes between the people who had their hernia repair done across three district hospitals and we compared it with those who went to have their hernia repair done in the national specialist hospital and we found that the outcomes were just as good in the district hospitals as they were in the national hospitals. That is an important type of evidence that actually show that we are giving as good care for these selective cases as they would get in the specialist hospital.
I think the bigger picture is how are we changing the face of surgery in the countries we are working in. We are now working in Tanzania as well as Malawi and Zambia but it is in Malawi and Zambia we have been working since 2011 and you can see there is a, you have to call it a transformation at the national level when they see what this research study has enable them to do and it has widespread support from national surgeons who really welcome the opportunity to go out into rural populations and ensure that that care is delivered.
But I even saw it right back to 2010, 2011, the very first time I visited Malawi and Zambia for this purpose. I had been working in this countries for far longer. I worked in areas like HIV and AIDS, Tb, malaria: they are the areas that people probably know best and I never got into see a chief medical officer or if I did it was just as part of a very broader meeting. But when they heard that we were bringing a surgical solution to meet the unmet needs in rural areas it was very easy to get in the door to them. We were actually responding to a strongly felt need from national ministries of health and increasingly the national surgeons welcome this as well. So there is just two insights into how we are transforming the whole approach to essential safe surgery for elective and emergency cases in Africa.
What would you say that are the challenges and expectations of the project?
We are not only trying to implement a kind of scale-up project, we are doing rigorous research and the way we know we are doing rigorous research is that we are publishing in some of the top surgical journals, international journals.
Doing research in these settings is very challenging. Fortunately we have a very committed team of researchers. I have a much easier job. I can sit here and talk to you about how wonderful it all is but if it wasn’t for people like Kuba and Chiara going out from Ireland and going down and working with Gerald in Malawi and Mweene in Zambia and Adinan in Tanzania, we wouldn’t be able to do what we promised to do. It is difficult. I do recall Kuba having to drive a thousand kilometres in Zambia just to get to one hospital. It is a big commitment, you really need very dedicated researches who are really committed to doing this and you need a kind of support system around.
I am just talking about my experience here in RCSI but it is the same with our colleagues in Radboud, in the Netherlands, and in Oxford, and we are building up a critical mass of surgeons and researchers in Tanzania, Zambia and Malawi. We also need to maintain the funding from the funders to keep this work going because the need is huge but we have got a very strong platform, a very strong base of what we are doing.
How SURG-Africa contributes to RCSI work?
Going to this area was for me like completing a circle, coming full time round to where I started 35 years ago, almost 40 years ago.
RCSI was going through a revision of its research strategy, has put surgery up there, as one of the top 6 pillars. What we are doing here through SURG-Africa we got funding now, funding is very important to say from the European Commission, we got a really large well-funded project twice from the European Commission, Irish Aids is now funding us for a project looking at breast cancer, cervical cancer screening in Malawi. This is enabling us to put into action what RCSI want to see as well so we are doing the global low and middle income country part of the surgical research. High level of support in RCSI for what we are doing. Recently with support from the Iris O’Brien Foundation, we have set up an Institute of Global Surgery, we are in the process of recruiting for it.
RCSI is making a very real commitment. RCSI surgeons have been long committed to quality assuring surgery in Africa, and I should mention the COSECSA collaboration which has been running successfully since 2008. It is running in parallel to what we are doing and they are focusing on the education and the training with the specialist surgeons in Africa.
RCSI has a big commitment about training specialist surgeons and now through the SURG-Africa project to training Clinical Officers. But not only Clinical Officers, SURG-Africa works with whoever is in the surgical team at the district hospital level and works with the general medical officers as well, it is about population approach to meeting those needs in the rural areas. RCSI is really full square behind us supporting this.