Abdul’s first birthday was a few weeks ago but without surgery he won’t survive to see another. He is one of millions of children in the world who has a condition that is only treatable with an operation. Like me, you may have needed surgery as a child, perhaps for acute appendicitis, to treat a broken bone, suture a laceration or, if you were particularly unlucky, to remove a tumour. Studies have indicated that up to 85% of children in Africa will require a surgical procedure before adulthood, partly a reflection of the high rate of trauma and burns in this setting. Abdul (not his real name) lives in Sierra Leone and is one of the unlucky children who had a tumour. He developed a cancer of his right kidney as a baby, called a nephroblastoma or Wilm’s tumour, named after the German surgeon who first described it. Although rare, it is the most common cancer of the kidney in children and is thought to have a higher prevalence in Africa. Like many patients here, Abdul presented to our hospital at late stage. His tumour had grown so large it filled most of his abdomen and was beginning to affect his breathing. Without surgery, it was clear he would not survive much longer.
Surgical care is hugely under-resourced in most low- and middle-income countries, such as Sierra Leone. Over the past few decades, the global health community has mainly focussed on infectious diseases such as malaria, TB and HIV, that are all treatable with medications or immunisation programmes. These are of course important, and substantial improvements have been made, but it has meant that conditions treatable with surgery have been left behind. One argument for focussing on infectious diseases is the huge burden that they have here. So what is the burden of surgical conditions at a population level? The reality might come as a surprise: more people die each year from surgically treatable diseases than deaths from TB, HIV and malaria combined. In fact, it is thought surgically treatable conditions account for a third of all deaths globally. A major reason for this is that 5 billion people in the world do not currently have access to timely, affordable surgical care when they need it.
There are many reasons for the lack of investment in surgical and anaesthetic care. To a large extent it is because governments and donors have been less willing to take on the complexity of this area of healthcare, compared with diseases that are treatable with medications alone. In addition, providing accurate estimates on the burden of surgical conditions is more challenging than a single disease such as malaria and giving accurate cost-benefit figures is difficult. Unlike many infectious diseases, the global surgical community has also failed to take on the challenge of highlighting the problem. The good news is that there are indications this is starting to change.
Paediatric surgery at Connaught Hospital in Sierra Leone is one example that is seeing the tangible effects of a new focus on surgical care. Following the tragic mudslides in Freetown last year, Orange Sierra Leone (www.orange.sl) noticed the essential work that was being done at Connaught Hospital, including by the surgical department. They provided funding to renovate two operating theatres in the hospital one for paediatric and one for orthopaedic surgery. The work was delivered by Goal (www.goalglobal.org), an organisation with extensive experience in infrastructure projects here. With a permanent presence in the hospital, King’s Sierra Leone Partnership (KSLP) were instrumental in advising on a number of the technical aspects and helped oversee much of the work. The result was that the two newly renovated theatres were opened last week by Dr Alpha Wurie, the Minister of Health and Sanitation for Sierra Leone.
In parallel with this, the Rotary Club of Ashburton and Buckfastleigh in the UK (www.rotary-ribi.org/clubs/homepage.php?ClubID=1015#) worked tirelessly to fundraise for the specialist equipment needed for the paediatric theatre. The project began nearly two years ago after a visit by the president of the club, Mr Andy Blackburn. Again, KSLP were central to identifying paediatric surgery as an area of need and a previous KSLP volunteer, Dr Ruth Tighe, worked to coordinate the project with the local team at Connaught. Identifying and sourcing the right medical equipment is no easy task. There are countless examples of donations where equipment from high income countries has been completely inappropriate for settings like Sierra Leone. Indeed, the World Health Organization has estimated that 70% of donated medical equipment to low resource settings is not usable on arrival at its destination. Rotary and KSLP worked hard to ensure that all the equipment would be both suitable and usable at Connaught. In addition, they wanted excellent value for money and decided to work with the Bristol-based company Freelance Surgical (www.freelance-surgical.co.uk) that specialises in both new and second-hand medical equipment. Astonishingly, Freelance provided much of the equipment at cost price and itself donated substantial amounts of kit. The result was that US$100,000 of funding has led to a procurement worth vastly more than this sum. Earlier this year, a UK-based charity, KidsOR (www.kidsor.org) also approached KSLP to consider how they might support paediatric surgery in Sierra Leone. Having seen the incredible work KidsOR has done in other African countries, we were keen they were involved. For the past few months, Rotary and KidsOR worked together to finalise the equipment donation and it arrived last week, in time for the visit by Dr Wurie.
This brings me the person at the centre of this project, Dr Aiah Lebbie, the paediatric surgeon at Connaught and the only one in the country. Originally from Kono, a town devasted by the civil war, he had the opportunity to specialise in paediatric surgery through a training programme funded by the BethanyKids (http://bethanykids.org) mentored by Dr Dan Poenaru, one of the world’s leading advocates for this work. Dr Lebbie is a quiet but dedicated man. Having personally seen him operate on children of all ages with a wide range of conditions, I can honestly say he is one of the best surgeons I have worked with. As an anaesthetist, I rarely compliment surgeons, but I can genuinely say that Dr Lebbie is brilliant at his job. To say Connaught is lucky to have him is a huge understatement – any paediatric hospital in the world would want him – but fortunately for Sierra Leone Dr Lebbie is totally focussed on providing care to children here. As testament to this, I have regularly seen him pay his own money to buy drugs, equipment and even the hospital costs of an operation so that children receive the care they need. It may sound extraordinary to anyone used to the NHS in the UK, but healthcare is not free in Sierra Leone and, although it should be for children under 5 years, it frequently fails in even providing this. Without question, Dr Lebbie represents the future of paediatric surgery in Sierra Leone and he already inspiring junior doctors here to consider a similar career path. It is wonderful to see so many international organisations support his work. But, as he told Dr Wurie during his visit, it is now time that the government steps up to play its part in addressing paediatric surgery here.
Of course, paediatric surgical care needs more than just a surgeon. It involves a wider team of nurses trained in paediatrics, junior doctors, operating theatre staff and, of course, anaesthetists. Paediatric anaesthesia requires specific knowledge and skills. In the UK there are additional training programmes for anaesthetists specialising in this field and , in total, it takes at least 8 years of training to become a consultant paediatric anaesthetist. But there are some basic principles that can be taught quickly and a short course is now available for anaesthetists working in low-income countries. It is called the SAFE Paediatric Anaesthesia course (www.wfsahq.org/wfsa-safer-anaesthesia-from-education-safe) and, with the support of KSLP and the World Federation of Societies of Anaesthesiologists (www.wfsahq.org), we are running a course for all the anaesthetic nurses and residents at Connaught Hospital later this month.
To me, all this work illustrates the value a partnership model such as KSLP can add to projects. With a permanent presence at the hospital, the team have a deep understanding of the local setting and the trust of staff. KSLP can offer the communication links between external donors and local teams, as well as between different donors that would otherwise work in isolation of each other. The end result is a coordinated strategy that is so often lacking with development projects. The value that KSLP has added in this example is hard to measure, but there is no doubt that paediatric surgical care is in a much stronger position now because of their involvement.
Abdul had his surgery two weeks ago. The operation would be risky in any setting – he needed half his blood volume replaced during surgery – but the tumour was removed successfully, weighing about a quarter of his body weight. Like many Sierra Leoneans, he is tough and within a week he was smiling in bed on the paediatric ward. He was discharged home a few days later. Abdul still has a long journey ahead but he now has a good chance of leading a normal life. The challenge for Dr Lebbie and for Sierra Leone is how to provide this care for more children like Abdul. The country clearly needs more than one paediatric surgeon and two physician anaesthetists, and the government must invest in this training, as well as in the nursing workforce. But for now, the projects described here represent an important moment for Connaught Hospital and for paediatric surgery in Sierra Leone and that should be celebrated.
All photos – Nick Boyd November 2018 (unless stated otherwise)