“Even if all newly graduated physicians worldwide over the next five years were to train to become surgeons or anaesthesiologists, it wouldn’t be enough to meet the global need”, says Lars Hagander, who is in charge of the new WHO Centre for Surgery and Public Health at LU.

It is a scary thing when people with surgical problems do not receive the help they require. In poor countries, especially in Africa and Asia, the needs within obstetric care and paediatric surgery are high. Even though the child mortality rate has decreased globally, the level of infant mortality is essentially unchanged. The main issues for the patient are the distance to hospitals, the lack of surgeons and not being able to pay for the treatment. The main challenges for surgeons are the difficulties of anaesthesia monitoring and the lack of blood.

“We see untreated fractures, burns and malformations. Neglected wounds, delayed C-sections. An inability to act in situations involving cancer diagnosis and treatment, and practically an epidemic of anaesthetic complications. Furthermore, the children arrive at hospitals so late that they are very frail. Being increasingly pressed for time means operations that are normally relatively safe become dangerous.”

The feeling of inadequacy made Lars Hagander want to change the underlying systems. What started as him providing hand-on assistance became a research initiative for a more sustainable process of change.

“As surgeons, we must raise our sights beyond the operating table. When it comes to global health, many people think of vaccinations, clean water and medicines, but internal medicine is not enough if you want to achieve public health goals. Most people only think of surgery as a resort when disaster strikes and then it becomes a selective measure. But in between disasters is everyday life and patients who suffer unnecessarily.”

Lars Hagander’s research team is behind the international collaboration, The Lancet Commission on Global Surgery, which in 2015 identified the conditions for surgery as a neglected part of healthcare in low- and middle-income countries. According to the report, the number of surgical procedures has to increase by over fifty per cent in order to save lives and prevent disability.

“Research moves our understanding forward and we have tried to use it to influence, enlighten and hold people accountable. There has been a lack of methods for how countries can best measure, evaluate and plan surgical care.”

Through cooperation with WHO, Lars Hagander has gained new opportunities in his research – partly through access to data and partly because the research findings can be communicated to health ministries in the respective countries in a completely different way.

“It’s external engagement deluxe, in keeping with the spirit of Hans Rosling. We visualise data and identify knowledge gaps. In the process, we engage those who we want to influence by conducting research together with the countries that face the potential of change. There is a notion of surgery as unsuitably costly for poor countries – however, a needle and thread is as cost-effective as vaccines. The return on investment is sky high, and it’s definitely more expensive to avoid surgery altogether.”

One of the key aspects of rapidly increasing access to surgery is task shifting. You simply train someone who is not a doctor to perform certain operations. To many, this is a provocative idea. Lars Hagander’s task as a researcher is to understand how much you can compromise on safety.

“In Sweden, surgery is so much about quality – you have to be a specialist, maximum safety is to be ensured and everything has to be top-notch. We have a hard time imagining a time when barber surgeons did the work. But in poor environments, the starting point is different and requires unorthodox solutions. For the sake of the patients, it’s important to respond to existing strong objections existing strong objections with research and knowledge. For now, we need to adopt both an acute and long-term approach within existing frameworks. This is a step in the right direction”, he concludes.

FACTS

• The WHO Collaborating Centre for Surgery and Public Health, focusing on global surgery, was inaugurated in September 2017, and is a collaboration between the World Health Organisation and Lund University.
• Through the work carried out in Lars Hagander’s research team and other initiatives, surgery has recently become a priority area for WHO.
• The research is to establish knowledge of how societies measure, evaluate and plan surgical care.

Lars Hagander:

Age: 43
Family: Wife Kathy and children Tom (17), Elliot (14), and Jonathan (12).
Profession: Associate Professor of Paediatrics and medical consultant in paediatric surgery
Currently: In charge of the new WHO Collaborating Centre for Surgery and Public Health at LU

Seibatu Sia Kemoh is 26 years old and was born in Sierre Leone, one of the African countries that has the greatest need for surgery. She works as a community health officer, with an education equivalent to a Swedish district nurse. She recently completed the two-year training programme in surgery, provided by a Norwegian charity organisation, CapaCare, which Lars Hagander’s research team is currently in the process of evaluating.

“People in the Sierra Leone countryside are not always able to get to the hospital for an operation. I wanted to participate in the programme to be able to help with minor surgery – especially involving complications in connection with childbirth.” says Seibatu Sia Kemoh.