How a trip to rural Kenya inspired a new approach to global surgery
By Mack Cheney
One year ago, before the Office of Global Surgery and Health (OGSH) existed, I traveled to Kenya. Although I understood the importance of such a trip at the time, it was not until recently, with the resolute power of hindsight, that I recognized just how much I learned during that trip and how much those lessons have impacted our approach to global surgery. Here are six things I learned in Kenya:
1. Think outside the capital
One of the first people I met after landing in Nairobi was Makawiti, a Kenyan orthopedic surgeon. Makawiti had worked for many years in Nairobi before an almost spiritual realization drew him 6 hours away from the capital to a rural area in Western Kenya. In Nairobi, he was one of dozens of orthopedic surgeons in the city; upon moving west, he became the only orthopedic surgeon for a population of over 5 million. Capitals are hubs of specialists and sub specialists accustomed to the luxuries of city life with little incentive to serve in rural communities. For most of the rural population, traveling for hours to a capital city is neither desirable nor financially feasible; as a result, morbidity and mortality rates from surgically treatable diseases remain high. It is because of stories like Makawiti’s that OGSH partners with medical schools outside of capital cities to expand surgical capacity at local institutions and reduce rates of referral to urban hospitals.
2. Health is more than just healthcare
I spent the majority of my time in Kenya with the Rogo family. The oldest brother, Dr. Kahma Rogo was the head of OBGYN surgery at a hospital in Nairobi for 20 years until shifting to the World Bank and a focus on Sagam, his rural hometown in Western Kenya. Together with his brother Nelson and Nelson’s wife Jane, Dr. Rogo has transformed his community. My tour of the town began at the local hospital, but it far from ended there. Along the main road Dr. Rogo pointed out the orphanage that Jane founded and runs, the vocational school, the water treatment facility, the community bank, the school, and several successful local businesses. This is a family that recognizes that healthcare is only a small part of building healthy, successful communities; OGSH now recognizes that fact as well.
3. Teach a man to ultrasound
During my trip I met Dan Price, the director of the Health and Human Rights program at MGH, who was in Kenya to introduce a new portable ultrasound machine. Rather than ship the ultrasounds to Kenya with a lengthy user manual written in English, he traveled there himself to provide intensive training for non-physician clinicians. After observing his training sessions and learning more about his approach, I saw the true value of exporting education, training, and mentorship rather than supplies, drugs, and buildings. Training and mentorship have become central to the OGSH model. Unlike other global surgery programs, we do not send doctors or residents abroad to perform surgeries; we send them abroad to build local capacity through training and research.
4. Respected, local clinicians are powerful
One of the most impressive people I met during my time in Kenya was Dr. James Wagude. I followed him on his rounds one day and was inspired by the impact that just one person could have. A crowd of residents, nurses, and other doctors formed around him wherever he walked, everyone eager for a piece of his wisdom and inspiration. It became clear to me that local surgeons committed to underserved communities make the best doctors and the best teachers. OGSH’s mission is to foster the development of more doctors like Dr. Wagude who have an acute understanding of the communities in which they work and the training to be an invaluable resource for future generations of doctors and medical staff. Our job at OGSH is to build a generation of accomplished surgeons who can replace us as local mentors for future generations.
5. “We must not be limited in our thinking”
During rounds with Dr. James Wagude, he stopped to quiz one of his residents on an assignment he’d been given the day before. Clearly ill prepared for this impromptu exam, the student mumbled a word or two before admitting he did not know. Dr. Wagude said nothing to the individual student but turned to address the entire group: “we may be limited by our investigations, but we must not be limited in our thinking”. This quote is as powerful now as it was that day, and it resonates across borders and oceans. The message for me is twofold. Do not allow misfortunes of circumstance to define your actions and an investment in knowledge development is more valuable than any medical equipment. Global surgery fully embraces these two truths by investing in people and education.
6. Partnering with local institutions is critical
While Dr. Price and Dr. Wagude demonstrated the power of training and mentorship, a visit to a rural operating theatre was a harsh reminder of the dearth of infrastructure in rural hospitals. As a Western doctor walking into the operating room pictured to the right, it’s hard to imagine ever putting knife to flesh in this type of environment. Infrastructure matters. While OGSH focuses on residency training programs, it is clear that facilities must be at a certain level in order for surgeons to perform to the best of their abilities. This is where local government can and must be involved. While we could raise a couple million dollars and construct a new operating theater, without government support and buy in it’s unlikely that this approach will be very sustainable. What OGSH can be best at is training residents and providing mentorship. What the government can be best at is setting the stage for sustained excellence at these hospitals. By partnering with ministries of health and incorporating residency training programs into existing state-run medical schools, global surgery will create a program that fosters collaboration between OGSH and African hospitals rather than dependence on Western institutions.
The themes of mentorship, collaboration, and capacity building resonate throughout each of these lessons and are the pillars on which we have build our OGSH program. As we are still in the early stages we must remain open to the many more lessons we have yet to learn, while still respecting the values now intrinsic to our model.