PHOENIX-As James D. Smith, MD, took his place behind the lectern to prepare to speak about what America’s role should be in the instruction of physicians in underprivileged and disease-stricken countries, a question was posed on the screen next to him: Do we have a responsibility to help?
Explore This IssueSeptember 2009
But it wasn’t really a question-it was more like a request.
Of course physicians in the United States should do what they can to bring medical education to struggling parts of the globe, said Dr. Smith, who himself has given a lot of time to overseas work.
Both he and Wayne M. Koch, MD, who introduced him, said our advantages in the United States put us in prime position to help.
Why do I think international medical education is important? Dr. Smith said during his John J. Conley Lecture at the 2009 annual meeting of the American Head and Neck Society, held as part of the Combined Otolaryngology Spring Meeting. Why should we even be concerned about helping? I think in North America and most of Europe, we have been blessed with opportunities and resources that most doctors in the world can only dream about. I have been in many countries where there are 400 to 500 medical students in each medical school class, only a few hundred beds to teach clinical medicine, and then only a few faculty to teach them. You can imagine making rounds with 40 or 50 students, one professor, and maybe one or two residents. If you’re student number 50 in the back, you really don’t hear much, let alone get any hands-on experience.
Dr. Koch said, North America has the best teaching and surgery and research in the realm of head and neck cancer in the world, and with that we have both an opportunity and an ethical obligation, I think, as we consider our responsibility as citizens in that world for teaching and reaching out.
Dr. Smith said that North American residency programs, with residents and faculty members working hand in hand, are not found in most other countries. I think one of the places where North America shines is in its postgraduate or residency training programs, he said. The concept of a rigorous, structured training program where the faculty actually assists and teaches a resident is not common in most countries. In most countries, the residents tend to watch, maybe assist, and then after they’ve seen enough cases, they are sent away to do the cases on their own, with little or no supervision.
Dr. Smith said he once saw the surgical logbook of a resident who had completed training. The resident had done one laryngectomy, one neck dissection, no oral resections, and no reconstructions-and this was in a developed country. I don’t say this to be critical, but to point out where we may be able to model and help in teaching head and neck surgery, he said.
African Nations Need Assistance
Dr. Smith talked about sub-Saharan Africa to bring into focus the needs of disadvantaged countries.
This area contains 11% of the world’s population. But the region accounts for 24% of the world’s disease and is home to only 2% to 3% of the world’s health workers, Dr. Smith said.
A lack of surgeons in developing countries is a particularly critical problem. Out of the relatively few health workers found in sub-Saharan Africa, a smaller proportion of them are surgeons than is generally found in other parts of the world. Meanwhile, surgical conditions account for 11% of the global burden of disease, caused mainly by trauma.
Most medical students don’t want to go into surgery, Dr. Smith said. It’s hard work. There is very little reward. And if you can go into infectious disease and then get a job-maybe with WHO working on HIV or malaria or something like that-you have the potential opportunity of getting an expatriate salary with much more income.
Ninety percent of the surgical disease found throughout the world is in developing countries, Dr. Smith said. There are 234 million major surgical procedures performed worldwide each year, which is twice the number of births in a year and seven times the number of HIV cases, according to a 2008 study (Weiser et al. www.thelancet.com July 22, 2008).
Although there is such a pervasive need for surgeons, they are not spread around the world evenly. Thirty percent of the world’s population receives 75% of the world’s surgical procedures. The poorest third of the world receives only 3% to 5% of all surgical procedures, that study found.
In some countries, the maternal death rate is as high as 10%, according to the study. It also has been estimated that, in pregnancies, about 10% will require Caesarean section and yet, in these countries, only about one in 20 women who need a C-section will have it available. So you can see that surgical disease qualifies as a major public health issue, Dr. Smith said.
The number of surgeons in African countries is severely low. In the United States, it has been estimated that there is one general surgeon for roughly every 17,000 residents. That doesn’t include surgeons who perform only specialized procedures.
In Kenya, that ratio is estimated to be 1:101,587; in Zimbabwe, 1:142,857; in Uganda, 1:270,000; and in Malawi, 1:800,000. In Mozambique, where there is one surgeon for every 305,085 people, 41 of the 59 surgeons in the country were expatriates who could pack up and leave at any moment, Dr. Smith said.
A big problem in countries in sub-Saharan Africa is that even the doctors who are trained there tend not to stay there, Dr. Smith said. Zambia has kept fewer than 10% of the 600 doctors trained there between 1978 and 1999. Ghana lost 630 doctors, plus more than 11,000 other health care professionals, between 1993 and 2002.
A recent survey of Nigerian medical students showed that more than 60% of them planned to emigrate after their training. And 17,260 African doctors and nurses joined the National Health Service in the United Kingdom in 2007, Dr. Smith said.
But, said Dr. Smith, the emigrating doctors can hardly be blamed. Physicians in sub-Saharan Africa sometimes make just $1000 a month, have to worry about their personal safety, and often do not have basic medications and surgical supplies. So when a recruiter comes calling, the temptation to leave is strong.
Why do people leave? I think it can be summed up in this one word: opportunity, Dr. Smith said. Would you or I stay? Of course not. Does that mean I don’t think we should help? No, I don’t think so.
-James D. Smith, MD
Movements Toward Change
There is work being done to try to change things.
The Pan-African Academy of Christian Surgeons (PAACS) has training centers fanned out across Africa to try to educate new surgeons. In 2002, there were just one program and only a few residents in training. In 2009, it is projected that there will be nine programs and more than 30 residents participating. Training sites are now located in Kenya, Ethiopia, Uganda, Nigeria, Cameroon, Bangladesh and Gabon. As of mid-2009, 10 African surgeons had graduated from PAACS programs and more were expected to graduate by year’s end. Five are practicing in their home countries.
The programs rely on visiting faculty. Those who volunteer use an English language curriculum and include surgeons of all specialties, as well as gastroenterologists, anesthesiologists, radiologists, and pathologists. The terms of service run from two weeks to six months.
Medical Education International, another group giving time to overseas training, sends teams of graduate physicians and dentists oversees to train, teach, and mentor other medical professionals. The aim is to build relationships with overseas colleagues to help them improve the health care of their own populations, including that of Kenya, where Dr. Smith has worked.
We’ve modified the courses to be more relevant to the countries that they’re in, Dr. Smith said. And one of most rewarding parts of this is that in the last two or three years we’ve been training the national physicians to give these courses, and they are now starting to do them around the country and want to start to do them in the countries around Kenya.
Just being able to communicate with the people teaching them was a big deal, he said. One of the things that was interesting was how much those attending appreciated the interaction with the faculty, Dr. Smith said. Most of them were used to being in medical schools where the faculty hardly would talk to them, and to have somebody answer your questions and have an interaction with was greatly appreciated.
Other relevant organizations include the AAO and REI in Vietnam and Cuba; the American College of Surgeons’ Operation Giving Back program, a resource meant to connect surgeons with volunteer opportunities, including those in other parts of the world; Operation Smile, a charity for treating facial deformities around the world; Medical Teams International, a Christian global health organization; and Smile Train, an international charity providing cleft lip and cleft palate surgery.
How to Get Involved
Dr. Smith-who also spent two and a half years working in Singapore, where he helped several training programs come together as one, improved program-suggested that those who want to volunteer overseas go with a friend or an established team the first time. They should research what is out there, whether it’s a chance to do lecturing, modeling of patient care, or evidence-based medicine or mentoring.
There are opportunities to volunteer for as long or as short time as doctors want. Terms can last for short periods of one to four weeks, intermediate periods of one month to a year, or longer terms of more than a year, he said.
Finding the time might be difficult, but the costs aren’t astronomical. Most of my trips run between $2,000 and $4,000 a trip, Dr. Smith said. This really depends on where you go, and the most expensive thing is usually the flight. But if you look at it compared to some of the medical tourism things that you can sign up for, it’s probably even less than that, plus it’s tax deductible. The most important thing is you really get to know the people that you visit on a personal basis.
He said that making such a trip at any point in one’s career has advantages. A resident might be able to spend more time on such a trip to see whether he or she really enjoys working abroad. Mid-career, a trip might make for an enriching sabbatical. And physicians would have more experience to offer if they made the trip toward the ends of their careers.
He cautioned that the trips can cause some strain on a doctor’s spouse, who might find the trips boring if they aren’t participating in the work. We do need to be sensitive to our spouses when we take these trips that are so interesting, Dr. Smith said.
The American Head and Neck Society, he said, could help by sponsoring visiting professor positions and conferences overseas, developing relationships with institutions in struggling nations, offering travel grants for residents, and holding virtual conferences.
I do hope that I stimulated some of you to consider helping in this arena, Dr. Smith said. No one is going to come to you and require you to give something personally, but as caring physicians, I hope that we will all stop, think, and ask the question: How can I help?
Donald Annino, MD, of Brigham and Women’s Hospital in Boston, agreed that such experiences are rewarding-he himself spent time in a similar program when he was younger-but he said that it is getting more difficult to find the time, especially for doctors in the middle of their careers.
I think there’s less ability economically, he said. As a resident, there’s a much greater chance that you’d be able to go and do that.
Ali Razfar, BS, a medical student at the University of Pittsburgh, said Dr. Smith’s lecture was helpful and encouraging. I certainly see myself doing it down the road, Mr. Azfar said. It’s personal growth. You get to share some of your knowledge with other people. You can learn a lot. It’s very humbling. I think it’s a good opportunity.
©2009 The Triological Society