September 24, 2015

The Need for Essential Surgical Care in the Developing World

Written by Dr. Tigistu A Ashengo, Jhpiego


When I return home to Ethiopia, I look forward to visiting my grandparents’ house to reconnect with uncles, aunts and cousins with whom I share a closeness that belies my bicontinental life. Growing up in Addis Ababa, I spent my summers at my grandparents’tukul, a cone-shaped mud hut nestled in the wide plains of the south that served as home, gathering place, familial retreat.

There were no secrets here—or so I thought.

The youngest of six children, my Uncle Mamo is a proud man who has spent most of his life farming coffee, teff (Ethiopia’s super-grain) and sugarcane. Sitting around the fireplace drinking coffee, we talked about everything from health and the family crops to religion and the neighborhood schools. I had forgotten how many children he had, so I asked.

At first, Mamo wasn’t certain himself. “I think seven, no eight. Oh wait, we lost one, so I  think seven,” he said. The first seven were all girls, and Mamo said, “We kept trying for a boy to help us with the farm when I get old.” But unfortunately, his wife developed a problem in her seventh pregnancy and the baby girl died.

That problem was vesicovaginal fistula, an abnormal opening between the vaginal canal and bladder, which his wife, Adanech, developed after a prolonged and obstructed labor. It’s a problem that could have been prevented if Mamo and his wife had decided to go to the health facility earlier and had enough savings to jump on a bus to get them there. Instead, they waited for a miracle of birth. But the labor during Adanech’s seventh pregnancy was difficult. She pushed for two days with little result.

After making the highly controversial decision to sell two of their cattle—a milk cow and a farming ox—they traveled the 18 kilometers so Adanech could deliver at Hosanna Hospital, a magnificent building that I recall admiring through a fence as a child.

Upon reaching the labor and delivery ward, they joined the misery of many women laboring—some on the floor, some sitting on a bench with their families. A nurse took Adanech with her relatives to a room where she examined her, naked, in front of both family and strangers.

Looking worried, the nurse set off to find the doctor on duty. As she did, she gave Mamo a prescription and told him to run to the pharmacy outside the hospital to buy IV fluids and lots of medications. The nurse also asked for two units of blood to be donated, as the hospital’s blood bank was closed.

After waiting another 24 hours for the doctor, medication and administrative processes, Adanech gave birth by cesarean section to a girl so distressed from the prolonged labor that she survived for a little more than 10 minutes, despite efforts by the health care workers.

Adanech slowly recovered from the operation and the grief of losing her baby girl. But before long she developed a new, but strange, problem—she was leaking urine as a result of her long and difficult labor. But fearing that her in-laws saw her as a weak woman for losing the baby, Adanech put off seeking help. By the time she told her in-laws about the fistula, months later, her condition had worsened, with symptoms of infection such as fever and a bad smell.

Adanech lived through the shame and stigma of this condition, but went on to have yet another child, which was very risky. Luckily, that time she made it to the hospital in time for a cesarean section. When I asked Mamo why he decided to have another child after all that Adanech went through, he said he had no idea how to prevent a pregnancy—and, once she was pregnant, “We thought it was going to be a boy this time . . . ” and indeed it was a boy.

This is a common story among many rural families in Ethiopia. Gaining access to health information, health facilities, emergency care and family planning services is a very complicated endeavor. To have to pay for it out of pocket makes it only worse.

In March of this year, the Lancet Commission on Global Surgery published a compendium of articles on the many facets of improving access to surgical care for people like Adanech. The commission estimates that about 33 million individuals face catastrophic expenditures from accessing surgical and anesthesia care each year on the basis of out-of-pocket costs of surgery alone.

In rural parts of Ethiopia, this disparity is even worse. According to a cost-effectiveness analysis in the third edition of the World Bank’s “Disease Control Priorities” (DCP3), surgical access in Addis Ababa, the capital, approximates that of high-income countries. In contrast, rural areas face the dual challenge of poor access and catastrophic economic conditions like those my uncle and his family faced.

Universal public financing of surgical care and use of non-specialist surgical care providers offer some hope for the poor, until highly skilled providers become available outside of urban and peri-urban areas. As the DCP3 states, “Impoverishment is not fully averted until patients no longer face non-medical costs of accessing care.” So providing essential and emergency services closer to the community shouldn’t wait until specialists are abundant.

Adanech would later have her fistula repaired at a hospital not far from where I grew up, but Ethiopian families like my Uncle Mamo’s shouldn’t have to choose between basic health care and income-producing cattle. Accessing health services shouldn’t endanger a father’s already fragile ability to provide for his family and, most important, a mother’s life. The ability to have a cesarean section, repair a fistula or remove a cataract shouldn’t hinge on a fistful of dollars or a professional tradition, but a health system dedicated to serving people wherever they live.


Tigistu A Ashengo, MD, MPH, is the Associate Medical Director of Jhpiego, a global health non-profit and affiliate of Johns Hopkins University. He is co-editor of and contributor to “ Operation Health: Surgical Care in the Developing World,” by Adam L. Kushner, Johns Hopkins University Press, 2015. A version of this article first appeared on Global Health Now.