A reflection from Lima: Global surgery and confronting systemic obstacles to change
Hi everyone, as promised we're working hard to deliver a multi-perspective view of global health work. So here's a post from one of my friends from Partners in Health/Socios en Salud!
Howdy! I am a graduate of Swarthmore College where I majored in Mathematics and Biology. During my college years I worked as an intern at the NIH Clinical Center, National Cancer Institute, and the Baltimore City Health Department while my postgraduate time has been spent as a volunteer with Socios en Salud in Lima, Peru. I am broadly interested in all things medicine and public health and hope to one day be a doctor and epidemiologist.
For the past few weeks I have been working for Socios en Salud (the Peruvian branch of the Boston-based NGO Partners in Health) on an evaluation of the surgical ward of a public hospital in one of Lima’s poorest neighborhoods. The project is motivated by a recent study from the Lancet Commission on Global Surgery that estimated the number of surgeries necessary to adequately treat health problems requiring surgical intervention in various populations around the world.
Although the words “global health” often invoke images of people suffering from exotic infectious diseases, conditions requiring surgical invention make up a surprisingly large chunk of global disease burden. One potentially mind-blowing statistic (via this study) to highlight this fact is that in 2010, conditions requiring surgical care caused the deaths of approximately 16.9 million people while HIV/AIDS, tuberculosis, and malaria (the three leading causes of infectious disease death globally) accounted for approximately 3.83 million deaths combined. In the case of the study I am helping with, previous calculations suggest that the hospital where we are working has not been meeting the surgical need of its catchment area. The objective of the study is to work with the hospital to devise a plan that will allow it to better meet the surgical needs of the surrounding population.
Working on this project for me personally has been fascinating, as until a few weeks ago I had zero interest in ever becoming a surgeon. Additionally I spend every day working in a public hospital abutted by various slums, which inevitably has led to numerous experiences that have affected my perspective on health and medicine. Nevertheless, the most impactful part of the project has been discussing the multitude of challenges that the hospital – and the larger Peruvian health system – faces with my colleagues at Socios and the nurses and surgeons at the hospital. These challenges take various forms: entrenched bureaucracy, professional disillusionment, strained class relations, the lasting scars of colonialism, kleptocracy, and the list goes on. What I’ve learned, however, is that it is very different to read about all of these sorts of problems in a newspaper or textbook than to confront them as part of an effort to improve people’s lives. Thinking about the substantial number of obstacles just this one hospital in Lima faces, I have recently been reminded me of a conversation I had a while back that contained some of the best wisdom about health and medicine I have heard.
The conversation in question was with a woman named Joneigh Khaldun who at the time was the Chief Medical Officer of the Baltimore City Health Department, where I worked as an intern in between my junior and senior years of college. She was an emergency room physician who continued to practice in addition to her duties as Chief Medical Officer, and I was speaking with her about the various challenges the Health Department faced. As with many problems in public health, these challenges were largely rooted in longstanding sociohistorical and institutional practices that felt fundamentally daunting to try and change. So I asked Dr. Khaldun if she ever felt like she should pare back her clinical practice and focus more efforts on attacking the population level issues. I don’t remember what she said verbatim, but it was along the lines of, “Well you’re probably not going to cure poverty. Of course that doesn’t mean you shouldn’t try to. But you also have to keep in mind that there are sick people out there right now, today, and you need to meet them somewhere. You can’t abandon them to work on these other issues, although those are very important, too.”
I have been thinking about this conversation because I’ve begun to accept that our project alone is probably not going to unilaterally solve the deep, socio-historical issues facing northern Lima’s surgical patients. But it will probably result in improvements that help a lot of people, not in the least part because the surgeons and nurses we have partnered with at the hospital care deeply about their patients and want positive changes to occur. Taking heart in this fact and learning to focus on the positive change we can effect has been an important lesson for me as a young person starting out in health and medicine. Hopefully other young people interested in global and public health adopt a similar approach as they set out to confront any of the many challenges we face today. And although it is unlikely no one project alone will solve all of the complex, meta-level problems in the world, perhaps the sum total our efforts can.