A 12-YEAR-OLD GIRL INVOLVED IN A MOTOR VEHICLE crash is transported to a district hospital in sub- Saharan Africa with a femur fracture and splenic laceration. Because resources and surgical personnel are limited, resuscitation efforts for the injured girl are inadequate. However, governments, the World Health Organization (WHO), funding agencies, and international nongovernmental organizations (NGOs) are beginning to reassess the importance of surgical services in developing countries and to prioritize the support, resources, training, and workforce required.
DISCUSSIONS OF GLOBAL HEALTH PRIORITIES focus naturally on the large number of patients with malaria, tuberculosis, AIDS, and other infectious diseases. The epidemiology of these diseases is complex and in its broadest sense includes the global socioeconomic structures responsible for their prevalence. A recent book, Awakening Hippocrates: A Primer in Health, Poverty, and Global Service, places global health disparities in a historical perspective and emphasizes the role of structural violence to the poor of the world as the result of human choices in the allocation of resources. While solutions to these global epidemics are being vigorously pursued with scientific research and socioeconomic interventions, we would, however, make a gentle plea for programs directed to the victims of war and violence, children born with congenital defects, and others who have
King County Medical Society Bulletin
By: Bill Thorness
DR. WAYNE LARRABEE’S practice has taken him around the world. The veteran Seattle facial plastic surgeon has operated over the years in many local hospital systems and developed his own surgical center. But he also has donned his scrubs in far-flung places on five
continents to do humanitarian work on cleft lip and palate deformities and facial surgeries necessitated by war injuries. During more than three decades as a physician, he has contributed countless hours to professional associations, publications and causes, and somehow devoted time and energy to raise a family and become an accomplished poet and photographer.
Epidemiology, Surgical Reconstruction, and Cost
by Travis T. Tollefson, MD; Joseph K. Wong, MD, FRCSC; Jonathan M. Sykes, MD; Wayne F. Larrabee, Jr, MD
A series of 46 procedures (42 patients) was performed on youth with cleft lip–palate deformities in Lanzhou, China. Patients’ ages ranged from 6 months to 18 years. There were no short-term complications in this series, which included many advanced cases. The estimated cost per patient was US $1590. Youth with unrepaired cleft lip–palate in western China can be treated in a cost-effective manner.
The neglected stepchild of global health
By: Paul E. Farmer and Jim Y. Kim
In Africa, surgery may be thought of as the neglected stepchild of global public health. There are fewer physicians per population on this continent than on any other; surgeons are rarer still, and almost all of them work in the urban enclaves of what remains a rural region. The story is the same in the poorer parts of Asia and Latin America (with a few exceptions, such as Cuba). Although disease treatable by surgery remains a ranking killer of the world’poor, major financers of public health have shown that they do not regard surgical disease as a priority even though, for example, more than 500,000 women die each year in childbirth; these deaths are largely attributable to an absence of surgical services and other means of stopping post-partum hemorrhage.
Surgery as a Public Good for Public Health
by Louise C. Ivers, Evan S. Garfein, Josue´ Augustin, Maxi Raymonville, Alice T. Yang, David S. Sugarbaker and Paul E. Farmer
Although surgical care has not been seen as a priority in the international public health community, surgical disease constitutes a significant portion of the global burden of disease and must urgently be addressed. The experience of the non–governmental organizations Partners In Health (PIH) and Zanmi Lasante (ZL) in Haiti demonstrates the potential for success of a surgical program in a rural, resource–poor area when services are provided through the public sector, integrated with primary health care services, and provided free of charge to patients who cannot pay. Providing surgical care in resource-constrained settings is an issue of global health equity and must be featured in national and international discussions on the improvement of global health. There are numerous training, funding, and programmatic considerations, several of which are raised by considering the data from Haiti presented here.
Socioeconomic Factors, Epidemiology, and Surgical Reconstruction
by Annette M. Pham, MD; Travis T. Tollefson, MD
In the African country of Zimbabwe, a variety of socioeconomic factors have contributed to a lack of specialty care and resources for the indigent population. Although cleft lip and palate has a lower incidence in Africa (0.67 per 1000 births) than in Latin America or Asia, access to reconstructive surgery is often difficult to obtain. A surgical team worked with Zimbabweans at the Harare Central Hospital, Harare, to perform cleft surgery for 39 patients. We review the epidemiology of cleft deformities in Africa, our experience with 39 patients with cleft lip and palate, and the techniques used to address 2 patients with midfacial clefts. To our knowledge, this retrospective case review and epidemiologic literature review is the first review of cleft care in Zimbabwe. Poverty in Zimbabwe, caused in part by the highest inflation rate in the world, has contributed to the emigration of a large number of specialists to other countries. In addition, the health care system is overwhelmed by a high prevalence rate of human immunodeficiency virus (25%), leading to a drastically reduced parental life expectancy (mean life expectancy, 36 years). Primary and secondary cleft lip and palate repairs were completed without complications. Children requiring care beyond the scope of this mission were referred to the Republic of South Africa. The cooperation among the Zimbabwean administration, physicians, and nurses was integral to the organization and successful execution of this reconstructive surgical mission. Ultimately, until the socioeconomic conditions improve in Zimbabwe, training and continuing education of local physicians are imperative to advance the care of children with cleft lip and palate.