Bringing Wound Care to Underserved Populations

In the United States, we take so much for granted, including our access to health care. Despite occasional problems, our access to needed treatments is available. But what if you had abdominal pain and were told you needed an appendectomy, yet there was no surgeon to remove your appendix? This is the case in many countries around the world. It is estimated there are 5 billion people worldwide who do not have access to needed operative care, much less anesthesia care.¹ It has been suggested there are 56 million people in need of an operative procedure at any time, and 1 out of 5 children and 1 out of 10 adults will die from lack of a simple operation.¹   These mortality figures are higher than those for HIV/AIDS, tuberculosis, and malaria combined.¹ 

The problem is a lack of surgeons and anesthesia personnel. There are 20 countries in Sub-Saharan Africa that have fewer than 20 surgeons in the entire country. Even the surgeons that are in a country will be concentrated in the largest cities with virtually no surgical care available in the countryside. It is estimated that more than 1 million surgeons are currently needed to bring minimum acceptable surgical care to the most underserved countries of the world.¹ The Lancet Commission on Global Surgery was established in 2014 to identify and develop programs to meet these needs by 2030. This effort includes recruiting and training surgeons, anesthesia personnel, operating room nurses, and other support personnel; developing the facilities where these procedures can be done; providing the equipment needed for safe operative procedures; and, of critical importance, providing access to these procedures to patients who are among the poorest in the world. The Commission’s stated goals are to make surgical care “available, affordable, timely, and safe and to ensure good coverage, uptake, and outcomes.”¹ This will be a monumental task.

While reviewing this 56-page report, it became apparent to me there was a missing component. In one of the lists of “essential surgical procedures,” wound debridement and management of traumatic wounds were noted as 2 of the top procedures needed. Interestingly, there was no mention of developing providers trained in managing wounds to provide these services and care. All of us know that wound care, including debridement, is not something considered “essential” in the training of physicians or surgeons in the United States, much less around the world. It is my opinion that limb salvage techniques and procedures are even more critical in under-resourced countries where amputees have little chance to get prosthetic devices, and resources for rehabilitation are limited if present at all. With diabetes mellitus being epidemic in every country in the world, expert management of complicated diabetic foot problems will be even more important.

Another missing aspect of the report is the management of patients with chronic wounds. With my experience treating wounds in Africa and other under-resourced countries, I can assure you that chronic wounds are a major problem. These patients are desperate for effective, affordable care. The Commission does not even mention this group of patients even though their treatment will fall to surgeons in most instances.

One group in Sub-Saharan Africa is already implementing a plan to address these problems. The Pan African Academy of Christian Surgeons is an organization utilizing American surgeons to train African surgeons to American educational standards and then sending them to work in their home countries in Africa. The organization currently has 10 surgical residency programs throughout Africa and will have graduated 45 residents by the end of 2015. There will be 98 graduates of the surgical residency programs by 2018.

Just as important to me is that these graduates will have seen the need for wound care training. Wound treatment for both acute and chronic wounds is a large part of their semi-annual basic science course, and a curriculum for wound care is being developed for each program’s use. These wound education efforts are being well received by the residents and program directors.

Wound care and surgical care in under-resourced countries should go hand in hand. It should be one of the surgical initiatives to provide wound care education and wound management resources in any surgical program. I hope to convince the Commission of this so that their plans can include wound care. I may need your help to accomplish this goal.