- Email: [email protected]
More than mothers: aligning indicators with women's lives
Comment
requiring specific therapy17,18—a personalised approach to donor organ management. Repair of acutely injured recoverable lungs will be the early gains of this approach. As we develop advanced lung regenerative strategies, use of molecular and cell treatments to repair lungs damaged by smoking is conceivable. Marcelo Cypel, *Shaf Keshavjee
6 7
8
9 10
Toronto Lung Transplant Program, University Health Network, Toronto, Ontario M5G 2C4, Canada [email protected]
11
We declare that we have no conflicts of interest.
12
1
2 3
4
5
Bonser RS, Taylor R, Collett D, Thomas HL, Dark JH, Neuberger J, on behalf of members of the Cardiothoracic Advisory Group to NHS Blood and Transplant and the Association of Lung Transplant Physicians (UK). Effect of donor smoking on survival after lung transplantation: a cohort study of a prospective registry. Lancet 2012; published online May 29. DOI:10.1016/ S0140-6736(12)60160-3. Eberlein M, Garrity ER, Orens JB. Lung allocation in the United States. Clin Chest Med 2011; 32: 213–22. De Meester J, Smits JM, Persijn GG, Haverich A. Listing for lung transplantation: life expectancy and transplant effect, stratified by type of end-stage lung disease, the Eurotransplant experience. J Heart Lung Transplant 2001; 20: 518–24. Botha P, Trivedi D, Weir CJ, et al. Extended donor criteria in lung transplantation: impact on organ allocation. J Thorac Cardiovasc Surg 2006; 131: 1154–60. Aigner C, Winkler G, Jaksch P, et al. Extended donor criteria for lung transplantation—a clinical reality. Eur J Cardiothorac Surg 2005; 27: 757–61.
13
14 15 16
17 18
de Perrot M, Snell GI, Babcock WD, et al. Strategies to optimize the use of currently available lung donors. J Heart Lung Transplant 2004; 23: 1127–34. Angel LF, Levine DJ, Restrepo MI, et al. Impact of a lung transplantation donor-management protocol on lung donation and recipient outcomes. Am J Respir Crit Care Med 2006; 174: 710–16. Klein AS, Messersmith EE, Ratner LE, Kochik R, Baliga PK, Ojo AO. Organ donation and utilization in the United States, 1999–2008. Am J Transplant 2010; 10: 973–86. Snell GI, Westall GP. Donor selection and management. Curr Opin Organ Transplant 2009; 14: 471–76. Castaldi PJ, Demeo DL, Hersh CP, et al. Impact of non-linear smoking effects on the identification of gene-by-smoking interactions in COPD genetics studies. Thorax 2011; 66: 903–09. Berman M, Goldsmith K, Jenkins D, et al. Comparison of outcomes from smoking and nonsmoking donors: thirteen-year experience. Ann Thorac Surg 2010; 90: 1786–92. Schiavon M, Falcoz PE, Santelmo N, Massard G. Does the use of extended criteria donors influence early and long-term results of lung transplantation? Interact Cardiovasc Thorac Surg 2012; 14: 183–87. Titman A, Rogers CA, Bonser RS, Banner NR, Sharples LD. Disease-specific survival benefit of lung transplantation in adults: a national cohort study. Am J Transplant 2009; 9: 1640–49. de Perrot M, Liu M, Waddell T, Keshavjee S. Ischemia-reperfusion-induced lung injury. Am J Respir Cell Mol Biol 2003; 28: 616–25. Christie JD, Sager JS, Kimmel SE, et al. Impact of primary graft failure on outcomes following lung transplantation. Chest 2005; 127: 161–65. Lee JC, Christie JD, Keshavjee S. Primary graft dysfunction: definition, risk factors, short- and long-term outcomes. Semin Respir Crit Care Med 2010; 31: 161–71. Cypel M, Yeung JC, Liu M, et al. Normothermic ex vivo lung perfusion in clinical lung transplantation. N Engl J Med 2011; 364: 1431–40. Cypel M, Liu M, Rubacha M, et al. Functional repair of human donor lungs by IL-10 gene therapy. Sci Transl Med 2009; 1: 1–9.
More than mothers: aligning indicators with women’s lives Just as pregnancy is one of many experiences in a woman’s life, reproductive health is only one crucial aspect of women’s health. Despite the many challenges women face worldwide, with a disproportionate burden in low-income countries, the public health community too often uses only reproductive health indicators when measuring progress in women’s health. This practice is shown most recently in the work of the UN Commission on Information and Accountability for Women’s and Children’s Health, the recommendations of which have the potential to shape how low-income countries collect data and report progress for years to come. The Commission has proposed six core indicators of women’s health: maternal mortality ratio; met need for contraception (proportion of women aged 15–49 years who are married or in union and have met their need for family planning); antiretroviral prophylaxis for HIV-positive pregnant women (prevention of mother-to-child transmission) and antiretroviral therapy for women who are eligible www.thelancet.com Vol 380 August 25, 2012
for treatment; skilled attendant at birth; antenatal care coverage; and postnatal care for mothers and babies.1 Five of these six indicators focus exclusively on women’s health in the context of reproduction. Indeed, the last four measure child health as much as that of women. Antiretroviral prophylaxis for HIVpositive pregnant women, while a highly effective intervention for preventing transmission of HIV to the infant, is not in itself a measure of women’s health.2,3 The inclusion of antiretroviral treatment for all eligible women, an important addition in later drafts, is the only attempt to expand these indicators beyond the reproductive period. Reproduction is a crucial high-risk period for women in low-income countries,4 but pregnancy is by no means the only time women are exposed to risk. In fact, WHO estimated that, in 2004, women in developing nations aged 15–59 years were less likely to die of maternal causes than of injury, including violence, HIV/AIDS, or cardiovascular disease.5 In terms of morbidity, this
Published Online October 4, 2011 http://dx.doi.org/10.1016/ S0140-6736(11)60757-5
711
Jorgen Schytte/Still Pictures
Comment
group of women lost the same number of healthy years—28 million—to maternal conditions as they did to neuropsychiatric disorders.5 WHO’s projections paint a similar picture for 2015, when the leading causes of morbidity and mortality for adult women in low-income countries are predicted to include HIV/AIDS (26% of years of healthy life lost), maternal causes (11%), neuropsychiatric conditions (10%), and cardiovascular disease (10%). In short, maternal conditions are one of several health challenges that pose substantial risk to this group of women.5 One approach to balancing the competing needs of streamlining indicators and broadening the concept of women’s health is the creation of a healthy woman scale. Such a scale, similar to the UN’s Human Development Index,6 would provide a benchmark against which countries could track their progress in creating an environment conducive to women’s healthy development over the life course. In addition to reproductive health indicators, such as maternal mortality ratio and met need for contraception, we propose this scale includes four measures. First, self-rated health is a reliable predictor of mortality and disability,7 which integrates women’s perspectives and provides insight regarding neuropsychiatric disorders8 and chronic disease.9 Second, women’s reports of intentional injuries, including self-inflicted injuries, violence, and conflict, would further elicit women’s perspectives on their experiences and identify effective intervention points.10 Third, an indicator of women’s empowerment, such as the 712
proportion of women who believe that wife beating is justified for any reason, should be used.11,12 Fourth, the proportion of women who have completed secondary education should be included, because this experience is linked to broad health outcomes for women and children, including HIV/AIDS,13 exposure to violence,10 and risk of neuropsychiatric disorders.14,15 The challenge of promoting women’s health is broader than the selection of indicators, which are inevitably insufficient. However, the measures we choose as a public health community not only determine the information we have, but also communicate our vision for healthy women and dictate the direction of future research and interventions. Broadening this set of indicators beyond maternal health sends a message that women are valued for more than their capacity to produce healthy children, and that success in meeting women’s needs reflects our belief that health is truly a state of “complete physical, mental and social well-being and not merely the absence of disease or infirmity”.16 Like the parable of the man who cannot discern the whole elephant by feeling only its trunk, a narrow focus on reproductive health obscures the broader picture of what it means to be a healthy woman. *Stephanie R Psaki, Funmilola OlaOlorun Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA (SRP, FO); and Department of Preventive Medicine and Primary Care, College of Medicine, University of Ibadan, Ibadan, Nigeria (FO) [email protected] We declare that we have no conflicts of interest. 1
2
3
4
5
6
Commission on Information and Accountability for Women’s and Children’s Health. Keeping promises, measuring results: Commission on Information and Accountability for Women’s and Children’s Health. Geneva: World Health Organization, 2011. http://www. everywomaneverychild.org/resources/accountability-commission/ documents (accessed Sept 28, 2011). Betancourt TS, Abrams EJ, McBain R, Fawzi MC. Family-centered approaches to the prevention of mother to child transmission of HIV. J Int AIDS Soc 2010; 13 (suppl 2): S2. Eyakuze C, Jones DA, Starrs AM, Sorkin N. From PMTCT to a more comprehensive AIDS response for women: a much-needed shift. Dev World Bioeth 2008; 8: 33–42. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–23. WHO. The global burden of disease: 2004 update. 2008. http://www.who. int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf (accessed May 26, 2011). UN Development Programme. Human Development Reports: the Human Development Index. http://hdr.undp.org/en/statistics/hdi (accessed May 26, 2011).
www.thelancet.com Vol 380 August 25, 2012
Comment
7 8
9 10
11
Jylha M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med 2009; 69: 307–16. Mackenbach JP, Simon JG, Looman CW, Joung IM. Self-assessed health and mortality: could psychosocial factors explain the association? Int J Epidemiol 2002; 31: 1162–68. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38: 21–37. Zavalaa DE, Bokongo S, John IA, et al. Implementing a hospital based injury surveillance system in Africa: lessons learned. Med Confl Surviv 2008; 24: 260–72. Abramsky T, Watts CH, Garcia-Moreno C, et al. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health 2011; 11: 109.
12 13
14
15 16
Rani M, Bonu S. Attitudes toward wife beating: a cross-country study in Asia. J Interpers Violence 2009; 24: 1371–97. Hargreaves JR, Bonell CP, Boler T, et al. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS 2008; 22: 403–14. Gupta R, Dandu M, Packel L, et al. Depression and HIV in Botswana: a population-based study on gender-specific socioeconomic and behavioral correlates. PLoS One 2010; 5: e14252. Lee J. Pathways from education to depression. J Cross Cult Gerontol 2011; 26: 121–35. WHO. Constitution of the World Health Organization as adopted by the International Health Conference, New York, 1946. http://www.who.int/ governance/eb/who_constitution_en.pdf (accessed May 26, 2011).
Augmenting surgical capacity in resource-limited settings Deficiencies in access to surgical care in low-income and middle-income countries are well recognised. Despite the awareness and benchmarks generated by the Millennium Development Goals,1 most sub-Saharan African nations have a negative annual growth rate in the number of physicians compared with their population growth rate.2 In several sub-Saharan African nations, there are only 0·9 physicians per 1000 population, compared with 21 physicians per 1000 population in the UK and 28 per 1000 population in the USA.3 These trends raise concerns about the morbidity, mortality, and disability-adjusted life-years lost due to injury and diseases requiring surgical treatment (including obstetrics) in sub-Saharan Africa.4 Policy makers and health-care leaders in Rwanda, a nation with only 0·1 general surgeons per 100 000 population (compared with 6·4 per 100 000 in the USA), have recognised the substantial negative socioeconomic effect caused by such deficiencies and have committed themselves to tackling these challenges. 5–7 A partnership has been created between the Faculty of Medicine at the National University of Rwanda and McGill University Health Centre, Canada, to build on the academic elements of the only surgical residency in Rwanda. A needs assessment was done revealing a substantial requirement to augment surgical capacity through growth of the existing programme. Historically, the residency training has been service based, with relatively few academic activities; a reflection of an overwhelming clinical workload and substantial staff shortages. These factors have resulted in a low intake of residents into the programme. Through the partnership, a system-based curriculum was developed, which is divided into 2-week modules covering locally relevant topics of general surgery. Each www.thelancet.com Vol 380 August 25, 2012
module contains lectures, resident case presentations, a journal club, morbidity and mortality rounds, and module evaluation by the residents. A Canadian surgeon, whose subspecialty is matched to the module topic, participates on a rotating basis in daily academic and clinical activities. This surgeon is not meant to replace local faculty in their responsibilities, but rather functions as an educator, moderator, and facilitator for the programme. Most activities are implemented by local faculty and residents. All activities are supervised by local faculty. These principles promote local programme accountability and, in keeping with the concept of “train the trainer”, form the necessary foundation for programme sustainability and success. This paradigm improves on previous models addressing the high morbidity and mortality from injury and surgical disease. Such models range from short-term, service-provision programmes, which, although they provide an exceptional service to individual patients, are heavily dependent on the donor organisation, to slightly longer programmes that focus on surgical education, such as essential surgical skills,8 and trauma.9 We now recognise that the highest impact programmes for increasing surgical capacity will be based on long-term partnerships focused on training of local physicians, thereby increasing information retention and sustainability. For the implementation of productive programmes, there are several important principles: local motivation and accountability, establishment of strong partnerships, understanding the local environment, curriculum development based on local needs and not on western models, early programme assessment, and substantial involvement of local partners for programme development. Additionally, the focus should be on
Published Online October 25, 2011 http://dx.doi.org/10.1016/ S0140-6736(11)61090-8
713
requiring specific therapy17,18—a personalised approach to donor organ management. Repair of acutely injured recoverable lungs will be the early gains of this approach. As we develop advanced lung regenerative strategies, use of molecular and cell treatments to repair lungs damaged by smoking is conceivable. Marcelo Cypel, *Shaf Keshavjee
6 7
8
9 10
Toronto Lung Transplant Program, University Health Network, Toronto, Ontario M5G 2C4, Canada [email protected]
11
We declare that we have no conflicts of interest.
12
1
2 3
4
5
Bonser RS, Taylor R, Collett D, Thomas HL, Dark JH, Neuberger J, on behalf of members of the Cardiothoracic Advisory Group to NHS Blood and Transplant and the Association of Lung Transplant Physicians (UK). Effect of donor smoking on survival after lung transplantation: a cohort study of a prospective registry. Lancet 2012; published online May 29. DOI:10.1016/ S0140-6736(12)60160-3. Eberlein M, Garrity ER, Orens JB. Lung allocation in the United States. Clin Chest Med 2011; 32: 213–22. De Meester J, Smits JM, Persijn GG, Haverich A. Listing for lung transplantation: life expectancy and transplant effect, stratified by type of end-stage lung disease, the Eurotransplant experience. J Heart Lung Transplant 2001; 20: 518–24. Botha P, Trivedi D, Weir CJ, et al. Extended donor criteria in lung transplantation: impact on organ allocation. J Thorac Cardiovasc Surg 2006; 131: 1154–60. Aigner C, Winkler G, Jaksch P, et al. Extended donor criteria for lung transplantation—a clinical reality. Eur J Cardiothorac Surg 2005; 27: 757–61.
13
14 15 16
17 18
de Perrot M, Snell GI, Babcock WD, et al. Strategies to optimize the use of currently available lung donors. J Heart Lung Transplant 2004; 23: 1127–34. Angel LF, Levine DJ, Restrepo MI, et al. Impact of a lung transplantation donor-management protocol on lung donation and recipient outcomes. Am J Respir Crit Care Med 2006; 174: 710–16. Klein AS, Messersmith EE, Ratner LE, Kochik R, Baliga PK, Ojo AO. Organ donation and utilization in the United States, 1999–2008. Am J Transplant 2010; 10: 973–86. Snell GI, Westall GP. Donor selection and management. Curr Opin Organ Transplant 2009; 14: 471–76. Castaldi PJ, Demeo DL, Hersh CP, et al. Impact of non-linear smoking effects on the identification of gene-by-smoking interactions in COPD genetics studies. Thorax 2011; 66: 903–09. Berman M, Goldsmith K, Jenkins D, et al. Comparison of outcomes from smoking and nonsmoking donors: thirteen-year experience. Ann Thorac Surg 2010; 90: 1786–92. Schiavon M, Falcoz PE, Santelmo N, Massard G. Does the use of extended criteria donors influence early and long-term results of lung transplantation? Interact Cardiovasc Thorac Surg 2012; 14: 183–87. Titman A, Rogers CA, Bonser RS, Banner NR, Sharples LD. Disease-specific survival benefit of lung transplantation in adults: a national cohort study. Am J Transplant 2009; 9: 1640–49. de Perrot M, Liu M, Waddell T, Keshavjee S. Ischemia-reperfusion-induced lung injury. Am J Respir Cell Mol Biol 2003; 28: 616–25. Christie JD, Sager JS, Kimmel SE, et al. Impact of primary graft failure on outcomes following lung transplantation. Chest 2005; 127: 161–65. Lee JC, Christie JD, Keshavjee S. Primary graft dysfunction: definition, risk factors, short- and long-term outcomes. Semin Respir Crit Care Med 2010; 31: 161–71. Cypel M, Yeung JC, Liu M, et al. Normothermic ex vivo lung perfusion in clinical lung transplantation. N Engl J Med 2011; 364: 1431–40. Cypel M, Liu M, Rubacha M, et al. Functional repair of human donor lungs by IL-10 gene therapy. Sci Transl Med 2009; 1: 1–9.
More than mothers: aligning indicators with women’s lives Just as pregnancy is one of many experiences in a woman’s life, reproductive health is only one crucial aspect of women’s health. Despite the many challenges women face worldwide, with a disproportionate burden in low-income countries, the public health community too often uses only reproductive health indicators when measuring progress in women’s health. This practice is shown most recently in the work of the UN Commission on Information and Accountability for Women’s and Children’s Health, the recommendations of which have the potential to shape how low-income countries collect data and report progress for years to come. The Commission has proposed six core indicators of women’s health: maternal mortality ratio; met need for contraception (proportion of women aged 15–49 years who are married or in union and have met their need for family planning); antiretroviral prophylaxis for HIV-positive pregnant women (prevention of mother-to-child transmission) and antiretroviral therapy for women who are eligible www.thelancet.com Vol 380 August 25, 2012
for treatment; skilled attendant at birth; antenatal care coverage; and postnatal care for mothers and babies.1 Five of these six indicators focus exclusively on women’s health in the context of reproduction. Indeed, the last four measure child health as much as that of women. Antiretroviral prophylaxis for HIVpositive pregnant women, while a highly effective intervention for preventing transmission of HIV to the infant, is not in itself a measure of women’s health.2,3 The inclusion of antiretroviral treatment for all eligible women, an important addition in later drafts, is the only attempt to expand these indicators beyond the reproductive period. Reproduction is a crucial high-risk period for women in low-income countries,4 but pregnancy is by no means the only time women are exposed to risk. In fact, WHO estimated that, in 2004, women in developing nations aged 15–59 years were less likely to die of maternal causes than of injury, including violence, HIV/AIDS, or cardiovascular disease.5 In terms of morbidity, this
Published Online October 4, 2011 http://dx.doi.org/10.1016/ S0140-6736(11)60757-5
711
Jorgen Schytte/Still Pictures
Comment
group of women lost the same number of healthy years—28 million—to maternal conditions as they did to neuropsychiatric disorders.5 WHO’s projections paint a similar picture for 2015, when the leading causes of morbidity and mortality for adult women in low-income countries are predicted to include HIV/AIDS (26% of years of healthy life lost), maternal causes (11%), neuropsychiatric conditions (10%), and cardiovascular disease (10%). In short, maternal conditions are one of several health challenges that pose substantial risk to this group of women.5 One approach to balancing the competing needs of streamlining indicators and broadening the concept of women’s health is the creation of a healthy woman scale. Such a scale, similar to the UN’s Human Development Index,6 would provide a benchmark against which countries could track their progress in creating an environment conducive to women’s healthy development over the life course. In addition to reproductive health indicators, such as maternal mortality ratio and met need for contraception, we propose this scale includes four measures. First, self-rated health is a reliable predictor of mortality and disability,7 which integrates women’s perspectives and provides insight regarding neuropsychiatric disorders8 and chronic disease.9 Second, women’s reports of intentional injuries, including self-inflicted injuries, violence, and conflict, would further elicit women’s perspectives on their experiences and identify effective intervention points.10 Third, an indicator of women’s empowerment, such as the 712
proportion of women who believe that wife beating is justified for any reason, should be used.11,12 Fourth, the proportion of women who have completed secondary education should be included, because this experience is linked to broad health outcomes for women and children, including HIV/AIDS,13 exposure to violence,10 and risk of neuropsychiatric disorders.14,15 The challenge of promoting women’s health is broader than the selection of indicators, which are inevitably insufficient. However, the measures we choose as a public health community not only determine the information we have, but also communicate our vision for healthy women and dictate the direction of future research and interventions. Broadening this set of indicators beyond maternal health sends a message that women are valued for more than their capacity to produce healthy children, and that success in meeting women’s needs reflects our belief that health is truly a state of “complete physical, mental and social well-being and not merely the absence of disease or infirmity”.16 Like the parable of the man who cannot discern the whole elephant by feeling only its trunk, a narrow focus on reproductive health obscures the broader picture of what it means to be a healthy woman. *Stephanie R Psaki, Funmilola OlaOlorun Department of Population, Family and Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA (SRP, FO); and Department of Preventive Medicine and Primary Care, College of Medicine, University of Ibadan, Ibadan, Nigeria (FO) [email protected] We declare that we have no conflicts of interest. 1
2
3
4
5
6
Commission on Information and Accountability for Women’s and Children’s Health. Keeping promises, measuring results: Commission on Information and Accountability for Women’s and Children’s Health. Geneva: World Health Organization, 2011. http://www. everywomaneverychild.org/resources/accountability-commission/ documents (accessed Sept 28, 2011). Betancourt TS, Abrams EJ, McBain R, Fawzi MC. Family-centered approaches to the prevention of mother to child transmission of HIV. J Int AIDS Soc 2010; 13 (suppl 2): S2. Eyakuze C, Jones DA, Starrs AM, Sorkin N. From PMTCT to a more comprehensive AIDS response for women: a much-needed shift. Dev World Bioeth 2008; 8: 33–42. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–23. WHO. The global burden of disease: 2004 update. 2008. http://www.who. int/healthinfo/global_burden_disease/GBD_report_2004update_full.pdf (accessed May 26, 2011). UN Development Programme. Human Development Reports: the Human Development Index. http://hdr.undp.org/en/statistics/hdi (accessed May 26, 2011).
www.thelancet.com Vol 380 August 25, 2012
Comment
7 8
9 10
11
Jylha M. What is self-rated health and why does it predict mortality? Towards a unified conceptual model. Soc Sci Med 2009; 69: 307–16. Mackenbach JP, Simon JG, Looman CW, Joung IM. Self-assessed health and mortality: could psychosocial factors explain the association? Int J Epidemiol 2002; 31: 1162–68. Idler EL, Benyamini Y. Self-rated health and mortality: a review of twenty-seven community studies. J Health Soc Behav 1997; 38: 21–37. Zavalaa DE, Bokongo S, John IA, et al. Implementing a hospital based injury surveillance system in Africa: lessons learned. Med Confl Surviv 2008; 24: 260–72. Abramsky T, Watts CH, Garcia-Moreno C, et al. What factors are associated with recent intimate partner violence? Findings from the WHO multi-country study on women’s health and domestic violence. BMC Public Health 2011; 11: 109.
12 13
14
15 16
Rani M, Bonu S. Attitudes toward wife beating: a cross-country study in Asia. J Interpers Violence 2009; 24: 1371–97. Hargreaves JR, Bonell CP, Boler T, et al. Systematic review exploring time trends in the association between educational attainment and risk of HIV infection in sub-Saharan Africa. AIDS 2008; 22: 403–14. Gupta R, Dandu M, Packel L, et al. Depression and HIV in Botswana: a population-based study on gender-specific socioeconomic and behavioral correlates. PLoS One 2010; 5: e14252. Lee J. Pathways from education to depression. J Cross Cult Gerontol 2011; 26: 121–35. WHO. Constitution of the World Health Organization as adopted by the International Health Conference, New York, 1946. http://www.who.int/ governance/eb/who_constitution_en.pdf (accessed May 26, 2011).
Augmenting surgical capacity in resource-limited settings Deficiencies in access to surgical care in low-income and middle-income countries are well recognised. Despite the awareness and benchmarks generated by the Millennium Development Goals,1 most sub-Saharan African nations have a negative annual growth rate in the number of physicians compared with their population growth rate.2 In several sub-Saharan African nations, there are only 0·9 physicians per 1000 population, compared with 21 physicians per 1000 population in the UK and 28 per 1000 population in the USA.3 These trends raise concerns about the morbidity, mortality, and disability-adjusted life-years lost due to injury and diseases requiring surgical treatment (including obstetrics) in sub-Saharan Africa.4 Policy makers and health-care leaders in Rwanda, a nation with only 0·1 general surgeons per 100 000 population (compared with 6·4 per 100 000 in the USA), have recognised the substantial negative socioeconomic effect caused by such deficiencies and have committed themselves to tackling these challenges. 5–7 A partnership has been created between the Faculty of Medicine at the National University of Rwanda and McGill University Health Centre, Canada, to build on the academic elements of the only surgical residency in Rwanda. A needs assessment was done revealing a substantial requirement to augment surgical capacity through growth of the existing programme. Historically, the residency training has been service based, with relatively few academic activities; a reflection of an overwhelming clinical workload and substantial staff shortages. These factors have resulted in a low intake of residents into the programme. Through the partnership, a system-based curriculum was developed, which is divided into 2-week modules covering locally relevant topics of general surgery. Each www.thelancet.com Vol 380 August 25, 2012
module contains lectures, resident case presentations, a journal club, morbidity and mortality rounds, and module evaluation by the residents. A Canadian surgeon, whose subspecialty is matched to the module topic, participates on a rotating basis in daily academic and clinical activities. This surgeon is not meant to replace local faculty in their responsibilities, but rather functions as an educator, moderator, and facilitator for the programme. Most activities are implemented by local faculty and residents. All activities are supervised by local faculty. These principles promote local programme accountability and, in keeping with the concept of “train the trainer”, form the necessary foundation for programme sustainability and success. This paradigm improves on previous models addressing the high morbidity and mortality from injury and surgical disease. Such models range from short-term, service-provision programmes, which, although they provide an exceptional service to individual patients, are heavily dependent on the donor organisation, to slightly longer programmes that focus on surgical education, such as essential surgical skills,8 and trauma.9 We now recognise that the highest impact programmes for increasing surgical capacity will be based on long-term partnerships focused on training of local physicians, thereby increasing information retention and sustainability. For the implementation of productive programmes, there are several important principles: local motivation and accountability, establishment of strong partnerships, understanding the local environment, curriculum development based on local needs and not on western models, early programme assessment, and substantial involvement of local partners for programme development. Additionally, the focus should be on
Published Online October 25, 2011 http://dx.doi.org/10.1016/ S0140-6736(11)61090-8
713