PAPS Papers

Partnerships for developing pediatric surgical care in low-income countries

There are several different models of education and care delivery models in low- and middle-income countries (LMICs), and many endeavors combine more than one of the described models. This article summarizes the burden of pediatric surgical disease and discusses the benefits and shortcomings of the following: faith-based missions; short-term surgical trips; partnerships, twinning, and academic collaborations; teaching workshops, “train the trainer,” and pediatric surgery camps; specialty treatment centers; online conferences, telemedicine, and mobile health; specific programs for exchange and education; and training in high-income countries (HICs), fellowships, and observorships. It then addresses ethical concerns common to all humanitarian pediatric surgical efforts.

Children born with congenital anomalies in low- and middle-income countries often face a multitude of challenges. Access to pediatric surgical services is limited because of a lack of medical facilities, an adequate transportation system, and a lack of trained surgeons, anesthesiologists, and nurses, all of which leads to a high mortality rate.

This is a report of a 5-y collaborative effort between the World Pediatric Project, the Children's Hospital of Richmond at Virginia Commonwealth University, and multiple organizations within the country of Belize to provide care for infants born with esophageal atresia, with or without associated tracheoesophageal fistula.

A total of six infants were transferred to our institution in Richmond, VA for operative correction of their esophageal atresia.

Caring for infants with congenital anomalies can be challenging, especially children from low- and middle-income countries. Through collaboration between countries and nonprofit organizations, life-saving international care can be provided to children for these conditions.

Disability-adjusted life years (DALYs) have become the standard metric for estimating burden of disease (BoD), but have not yet been applied to delayed access to surgical procedures. This study estimates the DALYs accrued from delayed access to surgical care in two pediatric surgical units in Kenya and Canada.

Records of operations for 13 congenital health states in a Kenyan and a Canadian hospital were prospectively collected for 2012. DALYs caused by delayed presentation were estimated using disability weights and ideal and actual age at surgery.

1208 first-time procedures in general surgery, neurosurgery, plastic surgery, and urology were included. Delays were longest in general surgery and longer in Kenya than in Canada in all specialties. The longest delays in Kenya were for orchidopexy (72 months) and anorectoplasty (PSARP) (74 months), and in Canada for orchidopexy (40 months). Corresponding total delayed BoD was highest in general surgery and neurosurgery and higher again in Kenya than in Canada (484 cf. 84 DALYs).

Estimating BoD resulting from delayed surgery is feasible and reflects both late presentation and limited access to care. Further exploration of these factors can make delayed DALYs a useful measure of health care coverage and waitlist prioritization.

The Hugh Greenwood Lecture acknowledges the extremely generous support from Mr Greenwood that has enabled the BAPS to establish funds to advance paediatric surgical training in developing countries. In this Inaugural Lecture, Dr. Sekabira, the first Hugh Greenwood Fellow, describes the influence that this has had on his career and reviews the state of paediatric surgery in Uganda.

Cellular therapy was introduced in the early 1980s as adoptive immunotherapy for cancer and has now expanded to stem cell treatment for a wide variety of indications. During the same period, the concept of the fetus as a patient evolved from fantasy to everyday reality. The intersection of these two fields offers great potential for cures in childhood diseases. The fetal treatment of spina bifida is one such disease. Global surgery has also emerged as a cost effective approach to reducing the worldwide burden of childhood disease.

A uniquely Ugandan method of holding surgical “camps” has been one means to deal with the volume of patients needing surgery and provides opportunities for global partnership.

We describe an evolved partnership between pediatric surgeons in Uganda and Canada wherein Pediatric Surgical Camps were organized by the Ugandans with team participation from Canadians. The camp goals were to provide pediatric surgical and anesthetic service and education and to foster collaboration as a way forward to assist Ugandan health delivery.

Three camps were held in Uganda in 2008, 2011, and 2013. A total of 677 children were served through a range of operations from hernia repair to more complex surgery. The educational mandate was achieved through the involvement of 10 Canadian trainees, 20 Ugandan trainees in surgery and anesthesia, and numerous medical students. Formal educational sessions were held. The collaborative mandate was manifest in relationship building, an understanding of Ugandan health care, research projects completed, agreement on future camps, and a proposal for a Canadian–Ugandan pediatric surgery teaching alliance.

Pediatric Surgical Camps founded on global partnerships with goals of service, education, and collaboration can be one way forward to improve pediatric surgery access and expertise globally.