Practicing medicine in a low- and middle-income country (LMIC) is a challenge—for everyone. Everything from human capital to clean water is in short supply relative to the massive demand. Access to care is low, complication rates high, and mortality rates tragic. Physicians are stretched thin and asked by flawed and underdeveloped systems to practice medicine within a broad spectrum of medical conditions. Specialized training programs are limited in number and subspecialization is rare to nonexistent in many LMICs. In this context, African Inland Church–Kijabe Hospital (AICKH) was an anomaly in that, as of 2010, it was able to offer multiple physician training programs, including surgical training in orthopaedic surgery, general surgery, pediatric surgery, and pediatric neurosurgery.
Founded in 1915 as a small, dispensary-type hospital ward, AICKH has grown to become a regional referral and training center. In 2007, East Africa’s first accredited pediatric surgical training program began under the direction of Daniel Poenaru, MD, FACS, FRCSC, a Canadian pediatric surgeon, and Richard Bransford, MD, FACS, the consummate missionary general surgeon whose practice in Kenya spanned decades and whose focus had become children with surgically treatable disabilities.
Dr. Bransford’s passion had birthed the not-for-profit Bethany Relief and Rehabilitation International, also known as BethanyKids, to care for children with surgical conditions, especially patients with spina bifida and hydrocephalus. The single pediatric surgical service cared for children with a broad spectrum of conditions, including neurologic, craniofacial, thoracic, gastrointestinal, urologic, trauma, and burn-related conditions. By mid-2010, a separate pediatric neurosurgical service under the direction of Leland Albright, MD, had been established and the pediatric surgical service focused on the remaining nonorthopaedic surgical conditions in children.
In 2010, a few short months after completing my formal pediatric surgery training in the U.S., my family and I relocated to Kijabe, Kenya, to join an effort begun almost a century earlier and carried on by hundreds of Kenyan and dozens of expatriate medical, administrative, and support personnel.
The pediatric surgery program I joined as faculty was run by BethanyKids at AICKH in conjunction with the Pan-African Academy of Christian Surgeons and accredited by the College of Surgeons of East, Central and Southern Africa. Somewhat naïve as to the breadth of the pediatric surgical practice at AICKH, I quickly realized that I needed to be simultaneously an educator and a student.
Training the trainer
“If you know it, you’ll use it,” was my father’s response to my complaints as a child and teenager of being expected to learn what I considered useless information in junior and senior high school. Working in a low-resource setting without a full breadth of surgical subspecialists to lean on, the truth of his admonition constantly rang true. Pediatric surgery in this context meant reconstructing the femoral artery of a child presenting with a pulseless lower extremity after a dog attack, resecting half the liver in a child with hepatoblastoma, and caring for the child with gastroschisis without adequate central lines or parenteral nutrition. It meant managing burn victims while relying on the living blood bank that is the hospital staff and surrounding community.
My general surgery training, then pediatric surgical subspecialty training, provided me with a strong foundation in the context of structured, formal didactic programs from which I could draw on past experiences. I was and am grateful for the breadth of training I received, but it is impossible to be trained or prepared enough for what will walk through the door when practicing in a LMIC.
When my general surgery program director, John “Tarp” Tarpley, MD, FACS, professor emeritus, Vanderbilt University School of Medicine, Nashville, TN, and head, department of surgery, University of Botswana, Gaborone, is asked how long it takes to train a surgeon, he replies, “A lifetime.” According to my review of cases at AICKH, 40 percent are outside the scope of the typical North American pediatric surgical practice, including complex pediatric urology and cleft lips and palates. Like many of my Kenyan colleagues, I was the fortunate recipient of informal training by visiting short-term surgical specialists and subspecialists. These surgeons are exemplary in their generosity and willingness to share their time, knowledge, and resources to “train the trainers,” so our trainees could gain valuable skills and knowledge in the broad practice of pediatric surgery.
I experienced the true power of short-term surgical volunteers in these types of strategic, capacity-building trips. However, the reality is that even though I performed and taught others to perform procedures like cleft lip and hypospadias repairs, I have never been an expert pediatric urologist or pediatric craniofacial surgeon. I worried about the inevitable gaps in knowledge and experience that can only be gained through focused, multiyear training under experts, usually as part of a formal training program.
My experience is that physicians of all types in LMICs are expected to practice much more broadly than most physicians in high-resource countries. The medical officer (a physician in her first post out of medical school) and sometimes the clinical officer (an advanced practice nurse or physician assistant) care for diabetes, hypertension, tuberculosis, human immunodeficiency virus, and malaria while on-call to perform cesarean sections, drain abscesses, or set bones. The pediatrician is expected to be the primary care provider, neonatologist, oncologist, nephrologist, intensivist, and emergency and critical care physician. The surgeon plates fractures, performs laparotomies, resects tumors, drills burr holes, reams prostates, removes thyroids, and corrects midgut volvulus.
On one level, I think this breadth is attractive to the hyper-specialized physician practicing in high-income countries and the increasing number of medical students and residents interested in a global health experience.1-4 Interestingly, and perhaps ironically, many of my African surgical colleagues at AICKH aggressively pursued subspecialty training in pediatric surgery, pediatric orthopaedic surgery, minimally invasive urology, plastic surgery, and head-and-neck surgery. I believe young surgeons are attracted to the expertise gained in a specialized field of study, which allows them to develop a deep and nuanced understanding of a narrower area of focus.
Moral injury
The caring and conscientious physicians feel the weight of their own ignorance. They want the best for their patients and work hard to be able to provide it. Perhaps the obvious conclusion is that the necessarily broad practice of medicine in an LMIC context precludes being an expert at everything. Should the lack of specialty expertise preclude offering care in that area? What is “good enough” when patients and their families have few or no options in their country or perhaps in an entire region of the continent where they live?
Five billion people, including 1.7 billion children, around the globe cannot access safe, affordable surgical care when they need it.5,6 Patients are desperate. At times, I saw patients who had traveled across several countries seeking care. The implications of turning them away because I lacked subspecialty fellowship training in an area were significant to the patients and their families. This reality left me asking myself, “Is something better than nothing?” I don’t know whether there is a universally applicable answer to that question. Sometimes the answer is a clear but heartbreaking, hope-dashing “no.” Other times, it’s a “yes,” filled with trepidation couched in a fundamental principle of “primum non nocere.”
The practice of surgery intrinsically requires a humble fortitude that includes a willingness to inflict pain for the greater reward that is the alleviation of suffering and restoration of health. At times, I found practicing on the edge of one’s expertise to be immensely trying, both emotionally and ethically.
“The only way not to spill water is not to carry water” was Tarp’s way of saying that surgical complications are unavoidable. AICKH physicians, medical and clinical officers, nurses, and health care workers in LMICs know how true this sentiment is.
Across the newborn, pediatric medical, and pediatric surgical inpatient units at AICKH, the overall death rate was 7 percent. During a 100-day national physicians’ strike in Kenya, December 2016–March 2017, the death rate at AICKH across these same pediatric services rose to 28.4 percent.7 In a study of perioperative pediatric mortality involving 24 government and nongovernment Kenyan hospitals (including AICKH) over a three-year period, January 2014–December 2016, the seven-day perioperative mortality rate for pediatric surgical cases was 1.7 percent—100-fold higher than in high-resource settings.8
Sometimes, such as during a strike, the demand overwhelms the imperfect system and patients suffer. Other times, physicians and other health care professionals make mistakes. Patients and their families must bear this reality, but so, too, do physicians who can become the second victim in the story.9
In 2018, Simon G. Talbot, MD, and Wendy Dean, MD, introduced me to the concept of moral injury when they asserted it as a major factor contributing to the more than 40 percent of U.S. physicians who report experiencing burnout.10 They posited that U.S. physicians are not burning out, but rather are suffering moral injury resulting from the “[inability] to provide high-quality care and healing” because of systems issues, such as financial conflicts of interest, fragmentation of care, and the deterrent to face-to-face physician-patient encounters posed by the demands of electronic health records, that inflict minor but frequent emotional wounds.
If, in the U.S., physicians experience moral injury and suffer “death by a thousand cuts,” how much deeper must be the wounds experienced by physicians in low-resource settings where supplies, personnel, training opportunities, finances, and functional health care systems are vastly more scarce. An underappreciated emotional toll accompanies the practice of medicine in a resource-constrained environment. Organizations like the United Nations provide “rest and recuperation” leave for workers in “hazardous, stressful, and difficult conditions,” because they have seen the deleterious effects of working in these settings.11 But what if the stressful environment is simply the daily work of providing health care in one’s home country or if the locale isn’t necessarily “hazardous” but fraught with imperfect systems of care that are unable to alleviate suffering adequately and avoid harm?
Many people working in LMICs deal with moral injuries routinely. Some respond by burning out and leaving medicine. Others suffer inurement and become complacent, believing real change is impossible. Still others find the strength to lean into the pain and work to change and improve the systems, sometimes at great emotional and personal cost. I believe everyone needs and can benefit from personal and professional support structures that provide the emotional space to process the perceived and real trauma of providing care in harsh circumstances.
Growing awareness offers new hope for underserved patients
Within the 100-plus years of AICKH’s existence, my eight-and-a-half years there were in some ways a drop in the bucket. But even with the hardships of working in an imperfect, under-resourced system, I developed relationships with Kenyan and expatriate staff who are brilliant and passionately committed to making life better for suffering children and their families. As a pediatric surgeon, I’m encouraged that amid the global health care need, awareness of the burden that surgical disease plays in children and adolescents is growing.12 The Global Initiative for Children’s Surgery was established in 2016 to bring together international multidisciplinary experts in pediatric surgery to offer solutions to surgical problems affecting children.13
Multifaceted efforts are under way globally that I believe will increasingly provide necessary surgical care to the 1.7 billion children in the world who desperately need it.6 We’ve seen the results of some of these efforts at AICKH. In the last nine years, AICKH has seen its first survivors of esophageal atresia and gastroschisis. A pediatric oncology service has been established, which is staffed by a subspecialty-trained Kenyan pediatric oncologist, specialty-trained nurses, and advanced practice providers.
Since 2007, 14 pediatric surgeons from 10 sub-Saharan African countries have trained, or are training, at AICKH. Nine of the 10 practicing pediatric surgeons are actively involved in training surgeons in their home countries.
Beyond that, John Kennedy Muma Nyagetuba, MD, the pediatric surgery program’s first Kenyan graduate, earned a master of business administration degree and now is program director of the pediatric surgery training program and chief executive officer of AICKH. He is leading efforts to disrupt and change the broken systems of health care within the region. AICKH serves as a site for East Africa’s first pediatric anesthesiology and first pediatric emergency medicine and critical care training programs in the region. These are just a few of the milestones that capture the work done at AICKH. Similar efforts and accomplishments are being seen throughout LMICs, and I’m grateful for the increased awareness of, and interest in, global surgery among students, trainees, and universities in the U.S. and throughout high-income nations.
As I reflect on the years my family and I spent in Kijabe, I’m struck by the strength and fortitude of the people with whom I was privileged to live and work. My Kenyan and expatriate colleagues were, and are, willing not just to show up, but to work, strive, sacrifice, suffer, and succeed in providing compassionate, holistic care to patients and their families. I learned more than I taught; I received more than I gave.
References
- Johnston PF, Scholer A, Bailey JA, Peck GL, Aziz S, Sifri AZ. Exploring residents’ interest and career aspirations in global surgery. J Surg Res. 2018;228:112-117.
- Powell AC, Mueller C, Kingham P, Berman R, Pachter HL, Hopkins MA. International experience, electives, and volunteerism in surgical training: A survey of resident interest. J Am Coll Surg. 2007;205(1):162-168.
- Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg. 2009;208(2):304-312.
- Hau DK, Smart LR, DiPace JI, Peck RN. Global health training among U.S. residency specialties: A systematic literature review. Med Educ Online. 2017;22(2):1270020.
- Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
- Mullapudi B, Grabski D, Ameh E, et al. Estimates of number of children and adolescents without access to surgical care. Bull World Health Organ. 2019;97(4):254-258.
- Adam MB, Muma S, Modi JA, et al. Paediatric and obstetric outcomes at a faith-based hospital during the 100-day public sector physician strike in Kenya. BMJ Glob Health. 2018;3(2):e000665.
- Newton MW, Hurt SE, McEvoy MD, et al. Pediatric perioperative mortality in Kenya: A prospective cohort study from 24 hospitals. Anesthesiology. 2020;132(3):452-460.
- Wu AW. Medical error: The second victim. The doctor who makes the mistake needs help too. BMJ. 2000;320(7237):726-727.
- Talbot SG, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. Statnews website. www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. July 26, 2018. Accessed March 4, 2020.
- United Nations. Administrative instruction: Rest and recuperation. Available at: www.un.org/Depts/OHRM/salaries_allowances/allowances/airnr.pdf. Accessed February 20, 2021.
- World Health Organization. Adolescent health. Available at: https://apps.who.int/gb/ebwha/pdf_files/WHA68/A68_15-en.pdf. Accessed February 20, 2020.
- Global Initiative for Children’s Surgery. Global Initiative for Children’s Surgery: A model of global collaboration to advance the surgical care of children. World J Surg. 2019;43(6):1416-1425.
