Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

Dr. Yousef Shahin

PS06_Yousef_Shahin_squareDr. Yousef Shahin

Chief Disease Prevention and Control, Health Department, United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), Jordan.

After graduating in Medicine and General Surgery at Zaprozyha Medical University in the Former USSR in 1985, he joined Jordan University of Science and Technology where he completed Master degree in Public Health in 1995.

Joined UNRWA in 1992 as Medical Officer in charge of health centers till 2005, when he was promoted to a senior position at UNRWA headquarters. He has more than 8 years’ experience in disease prevention and control programme, and responsible for the development, monitoring and evaluation of the UNRWA’s progrmme for disease prevention and control by preparing technical instructions, clinical guidelines, periodic assessment and supervision of related activities.

Dr. Shahin was designated to World Health Organization/ Eastern Mediterranean Region from July-December 2011 as Technical Officer on non- communicable diseases.

He has publications in medical journals including the Lancet on different health topics mainly diabetes care among Palestine Refugees. Participated in many international conferences and workshops addressing public health related topics.

GHF2014 – PS04 – Integrating Traditional and Alternative Medicine into Health Systems

10:45
12:15
PS04 TUESDAY, 15 APRIL 2014 ROOM: 18 ICON_Fishbowl
Integrating Traditional and Alternative Medicine into Health Systems
MODERATORS:
Dr. Edward Kelley
Director, Department of Service Delivery and Safety, World Health Organization, Switzerland
Dr. Bertrand Graz
Geneva University, ISG, Switzerland
SPEAKERS:
Making Heath Care Affordable to Poorest Communities Through Acupuncture: India
Mr. Walter Fischer
Founder and Project Manager, Barefoot Acupuncturists, India
Integrating Ayurveda: Clinical Studies on the Ayurvedic Treatment of Rheumatoid Arthritis Offer New Perspectives
Mr. Olivier Talpain
Associate researcher at the University Institute of History of Medicine and Public Health in Lausanne, Switzerland
Dr. Zhang Qi Coordinator, Traditional Medicine, World Health Organization, Switzerland
Research and integration of traditional/complementary medicines into the health system. The case of malaria in Mali and diabetes in Pacific islands.
Dr. Bertrand Graz

MD, MPH, Institute of Global Health, Faculty of Medicine, University of Geneva, Switzerland
OUTLINE:
Across the world, traditional medicine (TM) is either the mainstay of health care delivery or serves as a complement to it. In some countries, traditional medicine or non-conventional medicine may be termed complementary medicine (CM).Starting from specific experience, we will discuss WHO Traditional Medicine Strategy 2014-2023, which states that:"The demand for TM/CM is increasing. Many countries now recognize the need to develop a cohesive and integrative approach to health care that allows governments, health care practitioners and, most importantly, those who use health care services, to access T&CM in a safe, respectful, cost-efficient and effective manner. A global strategy to foster its appropriate integration, regulation and supervision will be useful to countries wishing to develop a proactive policy towards this important - and often vibrant and expanding - part of health care.
PROFILES:

Kelley_EDr. Edward Kelley

Dr. Kelley directs the Department of Service Delivery and Safety at the World Health Organization.  In this role, he leads WHO’s efforts at strengthing the safety, quality, integration and people centredness of health services globally and manages WHO’s work in a wide range of programmes, including health services integration and regulation, patient safety and quality, blood safety, injection safety, transplantation, traditional medicine, essential and safe surgery and emerging areas such as mHealth for health services and genomics.  Prior to joining WHO, he served as Director of the U.S. National Healthcare Reports for the U.S. Department of Health and Human Services in the Agency for Healthcare Research and Quality. These reports track levels and changes in the quality of care for the American health-care system at the national and state level, as well as disparities in quality and access across priority populations. Dr. Kelley also directed the 28-country Health Care Quality Improvement (HCQI) Project of the Organization of Economic Cooperation and Development. Formerly, Dr. Kelley served as a Senior Researcher and Quality Assurance Advisor for the USAID-sponsored Quality Assurance Project (QAP) and Partnerships for Health Reform Project Plus (PHRPlus). In these capacities, he worked for ten years in West and North Africa and Latin America, directing research on the Integrated Management of Childhood Illness in Niger. Prior to this, Dr. Kelley directed the international division of a large US-based hospital consulting firm, the Advisory Board Company.  His research focuses on patient safety, quality and organization of health services, metrics and measurement in health services and health systems improvement approaches and policies.

Physician and specialist in public health/international health (MPH from John Hopkins University

Dr. Bertrand Graz

Physician and specialist in public health/international health (MPH from John Hopkins University, today with Lausanne and Geneva universities), Bertrand Graz has been conducting development and research activities in Switzerland and in tropical countries, while keeping clinical activity as well. His doctoral thesis led to the validation of a non-surgical treatment for trachomatous trichiasis in Oman and China. After this, he has been leading many studies on the health effects of local traditional practices, such as  herbal treatments for malaria in Mali and diabetes in Palau, early rice feeding in Laos, Greek-Arab medicine in Mauritania, self-care for dysmenorrhoea in Switzerland. Now he aims at studying the effect of such research process in terms of optimisation of health resource's use and public health impact.

PS04_Walter_Fisher_squareMr. Walter Fischer

He has always needed to change lives and jobs whenever he knew he had hit the wall. Since early age, he chose traveling as a major mean to change and grow.  After 4 years of college, studying business and international trade, he started his professional career as export manager in a multinational. A few years later, he left and explored Asia. he went back to a (successful) business before definitely realizing that his way was elsewhere, in something hopefully more meaningful and useful to society. Studying and practicing acupuncture were a life changing experience to him. He finds it fair to share it with those most in need. He is a strong believer in the change we can bring together, with adequate tools and true intention. Humanitarian healthcare faces unlimited challenges, together with different and complementary professional approaches, situation of millions can be improved.

O_Talpain_squareMr. Olivier Talpain

As a former producer of fiction and documentary films myself, I particularly enjoy watching good documentary films. Thanks to Indian film maker Pan Nalin, I discovered Ayurveda for the first time, through his documentary film which struck me. I was impressed by the sophisticated holistic approach of the Ayurvedic system of medicine and the complexity of its medicines. Many Ayurvedic formulations are produced using tens of substances, through several long and complex processes. The testimonies of patients about unhoped-for recoveries touched me. I’ve eventually found it hard to believe that what seemed to be a remarkable blend of knowledge and know-how was kept aside and even threatened. Something didn’t make sense; I had to understand.

When I went back to university to study social sciences, I chose Ayurveda as the key issue of my research. I wrote the final dissertation of my Master in Development Studies on the recognition of Ayurveda through modern scientific research. I focused on two clinical trials on the Ayurvedic treatment of rheumatoid arthritis (1976-2012) that were funded by WHO and NIH-NCCAM. They both showed that the treatment gives positive results.

Still many questions remain. Why was the first study not published by the modern physicians in charge of it? Why is there so little research to assess Ayurveda? I am currently working on a PhD project to find some answers.

Zhang_Qi_squareDr. Zhang Qi

Dr Zhang Qi is leading the Traditional and Complementary Medicine Programme(TCM) in the Department of Service Delivery and Safety(SDS), WHO. He studied both conventional medicine and traditional medicine. He used to be a doctor, researcher and governmental official responsible for traditional medicine in China. He led the work of integration of traditional medicine services into national healthcare system in the department of healthcare services and headed the department of international cooperation, State Administration of Traditional Chinese Medicine, Ministry of Health In China. He used to lead the supervision on services, management and clinical research in the five hospitals affiliated to China Academy of Chinese Medical Science which is the national research institution for traditional Chinese medicine in China.

 

 

The perception of Family Medicine by Medical Student and Clinical Teaching Staff: Tajikistan

Author(s) Dilrabo Kadirova1, Jura Inomzoda2, Sabine Kiefer3, Erik van Twillert 4, Kaspar Wyss 5
Affiliation(s) 1Chair of Family Medicine Nb. 1, Tajik State Medical University, Dushanbe, Tajikistan, 2Chair of Family Medicine Nb. 2, Tajik State Medical University, Dushanbe, Tajikistan, 33Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 4Medical Education Project, Swiss Tropical and Public Health Institute, Dushanbe, Tajikistan, 53Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland.
Country - ies of focus Tajikistan
Relevant to the conference tracks Health Workforce
Summary The Tajik government is committed to promoting a family medicine model for Tajikistan. However, recent trends show that family medicine remains an unpopular choice among medical students. The study explores, in a cross-sectional survey, the perception of students as well as teaching staff on family medicine. Results show that several steps can be taken by the university to improve the perception of family medicine among students and staff (e.g. orientation events, early exposure to family medicine training). However, extrinsic incentives are perceived as the most promising drivers for changing students’ perception of family medicine.
Background The Tajik government is, in its National Strategy 2010–2020, committed to a family medicine model by which affordable primary health care should be introduced throughout the country. To successfully implement the strategy, reforming medical education to increase the number of family doctors is therefore a priority. The Swiss Agency for Development and Cooperation is assisting these efforts through the Medical Education Project (MEP) being implemented by the Swiss Tropical and Public Health Institute.Though the changes are on-going, it is being observed that many students and health workers find family medicine still unattractive. The number of interns registering for family medicine has, similar to other Central Asian Countries, decreased strongly over the last years.It is assumed that several factors during undergraduate studies influence the choice of specialisation. Among these factors are the mediated perception of family medicine through medical teaching staff as well as the students own perception. To increase the number of family doctors, it is essential to understand the perception of family medicine at different stages of a students’ lifecycle at university and the possible positive or negative influences of these through teaching staffs’ own perception of family medicine.
Objectives The objective of the study was to generate insight into the prevailing perceptions of family medicine among medical undergraduate students and teaching staff. Possible determinants including the influence of socio-demographic aspects and clinical teaching. The changes to students' perception over the course of study were also investigated.
Methodology In 2013 a cross sectional survey among 1st, 4th and 6th year students as well as all clinical teaching staff at the Tajik State Medical University (TSMU) was carried out by the chairs of family medicine. Perception of respondents towards family medicine was assessed through a set of items relating to family medicine. Respondents were asked to rate them on a 5-point Likert scale.
In total more than 2’500 students and more than 350 staff of TSMU were included in the study. The ratings were analysed through factor analysis to identify underlying dimensions in the perception items. Each factor was combined in a composite score to compare opinions of different groups using statistical tests for independent samples and outcome variables to investigate the influence of socio-demographics.
Results Students were mostly interested in working in specialities other than family medicine, most prominently surgery and obstetrics and gynaecology. In their speciality choice, students rated the possibility to work in Dushanbe and/or abroad, as well as prestige and salary very highly. Teaching staff reinforced these aspects as main drivers for students’ choices but also added that career opportunities/professional possibilities would play an important role. Overall students and staff of all three cohorts agreed that working as a family doctor is currently not very attractive in Tajikistan.
There was also large agreement that most students, as well as teaching staff, do not actually know what family medicine is really about. Moreover, students were convinced that society and other medical professionals have a low opinion and perception of family medicine.
Nevertheless, students showed themselves to be open to family medicine. Students and teaching staff both agreed that everyone should receive training in family medicine, no matter what specialty they choose later. Students supported the idea that family medicine should have the same prestige as any other speciality. This was seen differently by some teaching staff. However, students and teaching staff did not agree that family doctors should receive higher salaries than narrow specialists or that the access to specialists should be controlled by family doctors.
The majority of students did not recall any comments by teaching staff about family medicine. Of those who had heard about family medicine, many reported that the statements were neutral or positive.
More in-depth results are currently being analysed and will be presented at the Geneva Health Forum 2014.
Conclusion The study provides insight into Tajik medical undergraduate students’ perception of family medicine and indicates that targeted interventions are necessary to increase the interest and commitment of students to become family doctors.
Several steps can be taken in conjunction with the university, the chairs of family medicine and through the medical education curriculum to improve students and staff perception of family medicine.
Given the low level of knowledge of family medicine, it is concerning that students and staff have a rather bad perception of family medicine. The majority of teaching staff and students were unfamiliar with family medicine. Once students enter university orientation and information events are essential. Contents of family medicine lectures, as well as career pathways, should be presented to the students. Similarly, information and promotion activities for the teaching staff would lead to a better perception of family medicine. Adapting the curriculum to provide an earlier and intensified exposure to family medicine training is required. Attractiveness and participation in practical trainings in family medicine should also be incentivised.A higher appreciation of family doctors, through extrinsic incentives, would positively change student perceptions. The most important aspects for students choosing a speciality were those which currently cannot be offered by family medicine positions in Tajikistan, specifically the placement in the Dushanbe or the higher prestige of a speciality. These aspects need reforms and continuous efforts from the Tajik Ministry of Health to better the conditions for family doctors and provide incentives for students to take up family medicine. Incentives for students need to be well-designed and structured to ensure that they truly raise students’ interest in family medicine. Beside higher salaries for the family doctors compared to other narrow specialities, this could include mandatory internships in family medicine.Based on the Tajik national health sector strategy, a strong political commitment from the government outlining the possible career pathways and opportunities for family doctors would clearly enhance the perception, value and popularity of family medicine.

Increasing Access to Surgical Services in Resource-constrained Settings

Author(s): J. von Schreeb*1, S. Luboga2, S. Macfarlane3, M. Kruk4
Affiliation(s): 1Division of International Health, Karoliniska Institute, Stockholm, Sweden, 2Department of surgery, Makere University, Kampala, Uganda, 3Global Health Sciences, University of California San Francisco, 4Health Management and Policy, University of Michigan, School of Public Health, Michigan, United States
Keywords: Surgery, district, hospitals, training
Background:

Surgical services provide important preventive and life-saving strategies. Contrary to prevailing opinion, essential surgical procedures can be provided in district hospitals at a cost per DALY equivalent to other well-accepted preventive procedures. An international group of health professionals met last year at the Rockefeller Foundation’s Bellagio Center to develop strategies to raise the profile of surgery and increase access in resource-constrained settings in Africa. The group agreed that the major limiting factor in providing access is the shortage of suitably skilled health workers at district hospitals. The presentation is compiled on behalf of the Bellagio Essential Surgery Group.

Summary/Objectives:

 The objectives of the presentation are to: 1) outline what is known about the unmet need for surgical services in Africa and gaps in our knowledge; 2) layout obstacles to access; 3) examine alternative strategies to increase appropriate workforce skills; and 4) call for wider partnerships to integrate surgery within primary healthcare and develop training strategies.

Results:

The results are based on a literature review conducted prior to the Bellagio Conference and a synthesis of experiences of participants from Eritrea, Ghana, Kenya, Mozambique, Southern Sudan, Sweden, Tanzania and Uganda, and USA. A significant burden of disease is attributable to surgical conditions in sub-Saharan Africa but that much more evidence needs to be generated in order to better target interventions. A major proportion of these conditions can be treated or prevented cost-effectively at the first referral level but that this will require investments in facility infrastructures and in the training of non-surgeons to perform basic life saving general and obstetrical surgery. Preventive and curative programmes to address basic surgical conditions could strengthen health systems in resource-constrained settings and every effort should be made to develop these programmes in an integrative manner. Preventive and curative surgical interventions are essential to health systems and should to be integrated into primary healthcare strategies.

Lessons learned:

More effort is required to raise the profile of surgery on national and international agendas. In the first instance, there is need for: 1) more research to fill gaps in knowledge; 2) demonstration models of provision of surgical services at district level; and 3) sharing, through partnerships, of country experience in training non-surgeons in basic surgical procedures.

Access to Reproductive Health Services in Rural Haryana, India: Pertinent Issues and Concerns

Author(s): A. K. Aggarwal1
Affiliation(s): 1School of Public Health, Postgraduate Institute of Medical Education and Research, Chandigarh, India
Keywords: Reproductive health, access, quality of care, community survey
Background:

Better access to healthcare is a global challenge. Increased amounts of funds are allocated nationally and internationally to improve access. Therefore, understanding access at local levels helps to focus the policies and strategies.

Summary/Objectives:

To study utilization of pubic health facilities for reproductive healthcare. 2) To identify important access issues from community’s perspectives.

Results:

Women tend to consult government and private doctors for the problems associated with use of family planning method. For reproductive tract problems, however, private doctors are preferred over govt. doctors. For institutional deliveries and emergency obstetric care this gap was much more pronounced, with private practitioners taking the lead over govt. health institutions. The major reasons for these as elicited through various focused group discussions were uncaring attitude of health service provider, resulting in delayed initiation of treatment. Other important reasons from community’s perspective were lack of availability of govt. doctors, and insufficient medicines. Lack of faith in public health services drives them to private practitioners that are costlier. Treatment often gets delayed in the process of arranging money. Such delays become fatal for maternal complications, as was evident from maternal mortality enquiry. Health centres were observed for availability of health facilities. Only 56% sub-centres are located in govt. buildings. Approachability of most of the sub-centres was poor especially in rainy season. At community health centre (CHC): first level of health centre where specialists in medicine, surgery, paediatrics and obstetrics should be available, money is charged for routine investigations. This is an important deterrent for many women. Unorganized antenatal care set-up, interpersonal conflicts between service providers, poor management and, co-ordination of services and vested interests reduce access of services to the clients. Only normal vaginal deliveries are conducted at this CHC and for all complications women are referred to district hospital. Ambulance for referral is available but is not accessible to all due to lack of awareness on the part of users, and lack of proactive approach and supervised referral on part of health providers. Treatment at government health facilities consumes more time, and people have to pay money to avail these services. Although cash expenditure is more in private hospitals, but time was considered as more precious than money by most people in this area. For others, even small amount levied upon at government facilities was deterrent. Service environment was found to be very poor at all levels. Our observations indicate that technical incompetence was an important contributor for mismanagement of reproductive problems and maternal complications. Lack of inventory management skills and human resource management skills resulted in frequent vaccine stock-outs and non delivery of services. Technical gaps were also observed through prescription audit. Emergency obstetric care services are practically not available at CHC. All such complicated cases arriving here should have gone directly to district hospital. The information gap exists because of stereotyped thinking in community and among health providers that referral chain from sub-centre to PHC, CHC, and district hospital should be followed irrespective of type of complication and availability of facilities to tackle the complication.

Lessons learned:

Investment on improving management skills, financing mechanisms to cut treatment delay due to immediate non availability of money, putting in place better maintenance structures for building, equipment and supplies, and technical strengthening of health staff may help build faith of community in public health services and improve access.

Where Do Chinese Health Professionals Stand on Issues of Migration to the West

Author(s): H. H. Dib*1, X. Qiang2, Q. Liu3, S. Wei4, L. Li5
Affiliation(s): 1Health Care Management, Dalian Medical University, Dalian, 2Psychiatry hospital, An Ding Hospital affiliated with
Capital Medical University, Beijing, 3Statistics department, School of Public Health, Dalian Medical University, Dalian, 4Thoracic Surgery, First Hospital of Tsinghua University, 5Traditional Chinese Medicine, Beijing Friendship Hospital affiliated with Capital Medical University, Beijing, China
Keywords: Migration, health professionals, obstacles, level of education
Background:

Investigate the tendencies and obstacles facing Chinese health professionals in migrating to western countries

Summary/Objectives:

A qualitative survey interviewed 540 from different ranks in health professions and education level from three hospitals-Psychiatric Hospital (n=289); General Hospital (n=125), Chinese-Western Combination Hospital (n=126)

Results:

1 – Working abroad to enhance professional skills versus level of education, years of experience, and barriers to migrate significant differences were detected (P<0.05 to P<0.0001) (Table 1).
2 – Migrating and coming back is an advantage versus type of profession, level of education, barriers to migrate, reasons for migrating showed significant differences (P<0.05 to P<0.0001).
3 – Willingness in investing for higher nursing degree to migrate for financial purposes versus professions, years of experience, barriers to migrate, previous years of experience abroad or planning to work abroad, work experience in big Chinese cities showed significant differences (P<0.05, P<0.001 to P<0.0001).
4 – Lack of equity in investing for intensive nursing courses and/or training for license exams versus barriers to migrate, reasons for migrating, years of experience and/or planning to work abroad showed significant differences (P<0.05).
5 – Obtaining international certification in working abroad versus barriers to migrate, and reasons for migrating showed significant differences (P<0.05).
6 – Comparing future migration versus years of experience showed significant differences (P<0.05).
7 – Working abroad to enhance professional skills between groups among different ages showed significant differences (P<0.05).
8 – Migrating and coming back as an advantage between groups among different ages showed significant differences (P<0.05).
9 – Willingness to invest for higher nursing degree or training for license exams between groups among different ages showed significant differences (P<0.0001).
10 – Lack in equity for investing in intensive nursing courses between groups among different ages showed significant difference (P<0.05).

Lessons learned:

Major obstacles facing Chinese health professionals are of working abroad are language barrier, lack of equity, and international certification. There is a fertile health human resources training market targeting especially nurses, which could boost the increasing number of high quality nurses and absorbed in the western countries through to boost their healthcare systems.

Evaluation of the Improvement of Nursing Staff Working Overtime for the Medical Centre in Southern Taiwan

Author(s): S. C. Hsu*1, H. F. Lee1, C. W. Chang1, Y. C. Li1, C. L. Chang1, H. H. Huang1, S. L. Ding1, Y. C. Hsieh1
Affiliation(s): 1Nursing, Chimei Medical Centre, Tainan, Taiwan
Keywords: Nursing staff, working overtime
Background:

Nursing care quality is an important indicator for the safety of patients. Working overtime will increase the physical and psychical stress of the nursing staff, decrease the satisfactory degree of their nursing careers, and reduce their wills of retaining their posts. Moreover, the nursing care quality and safety of patients will also be highly influenced.

Summary/Objectives:

The purpose of this study investigates the present status of nursing staff working overtime, the correlative factors that affecting working overtime, and the effects of interventions for working overtime. The participants for the data collection are the staff of 35 nursing units of the Chimei Medical Centre in Southern Taiwan. A questionnaire is designed for the participants to understand the present status of working overtime and its correlative factors. Finally, the feasible interventions to improve overtime are carried into execution.

Results:

441 copies of questionnaire are sent to participants, and the retrieve rate is 80%. Working overtime is most frequently happened on day shift. Working over 60 minutes in day shift is about 69.3%. Among the investigated 35 units, the worst cases of working overtime are on internal medicine and medical surgery departments (especially on general surgery, hematology, and oncology units). Their average overtime is about 120 to 150 minutes. The correlative factors that affecting working overtime include the disobedience to hospital policy by medical team, the incompletion of medical orders, the poor arrangement of nursing manpower, the complication of nursing record contents, and too many repeated record forms. The feasible interventions to improve working overtime include the coordination of ward deployment policy and order rules with medical team, the re-arrangement of nursing manpower, and the simplification of nursing record documents. After carrying out the interventions, the average working overtime of nursing staff is reduced to less than 60 minutes.

Lessons learned:

With the aid of medical team cooperation and working process simplification, the working efficiency and overtime of nursing staff can be improved.

The ‘Rural Surgeon’ of India: A New Paradigm in Surgical Education

Author(s): K. M. Shyamprasad*1, M. Gautham2
Affiliation(s): 1Surgical Education, National Board of Examinations, 2Public Health, Independent consultant, New Delhi, India
Keywords: Rural surgeon, innovative training, skill mix
Background:

There is a wide gap between the burden of surgical emergencies and diseases in India and the availability of appropriately skilled surgeons to manage these, especially for the country’s 700 million rural population. On the public health forefront, huge surgical needs exist for management of (1) maternal complications and emergencies that are a leading cause of India’s high maternal mortality rate (407/100,000 live births), and (2) injuries responsible for 11% of deaths, 50 million hospital care seekers, and 17 million hospitalizations. The country needs to develop greater numbers of versatile surgeons able to function independently in resource limited rural settings.

Summary/Objectives:

In a significant shift from the Euro-Western model of compartmentalized surgical education, the National Board of Examinations - the MoH’s apex body for post graduate medical education - has developed a 3 year Rural Surgery course. The syllabus emphasizes basic surgical skills and management of traumas and emergencies; it includes Obstetrics and Gynaecology, Anaesthesia, as well as Management of a Rural Health Centre. Problem solving learning principles underlie the pedagogical approach. Nodal and peripheral rural course centres, chosen for their commitment to rural surgical care, provide practical training in cost containment, economics of rural healthcare, functioning within infrastructural constraints, and also inculcate appropriate attitudes and communication skills. Student’s learning material is responsive to local disease burdens and incorporates a variety of e-learning and audiovisual material.

Results:

The course was launched in 2007 with 10 students. Periodic reviews are designed to improve upon the basic course design and attract increasing numbers of students.

Lessons learned:

The Rural Surgery course is an innovative, pioneering effort to align surgical education with the public health surgical burden of a low income country. It represents a paradigm shift in the evolution of Indian medical education from a Western model to a locally responsive model.

Facing Logistics of Cataract Surgery: The Moka Hospital Experience in Mauritius

Author(s): C. Tabatabay*1, A. Fong2, B. Gruson2
Affiliation(s): 1Medical practice, 2University Hospitals of Geneva, Switzerland
Keywords:

Ophthalmology, cataract, humanitarian, teaching, eye, surgery, Mauritius, competence, waiting list, Moka Hospital

Background:

1 – The only ophthalmic hospital in Mauritius lies in Moka and has a large surgical activity including about 2500 inpatient cataract operations per year in two operating rooms out of the three existing ones. But there was a waiting list of about 3500 cases which represented a waiting period of over one and a half years.
2 – By opening a third operating room already equipped but not yet fully operational, we would be able to increase the amount of cataract surgery realised. The waiting list for cataract surgery problem would then be solved within the next coming months.
3 – The ultimate goal is a better use of the human and local resources to upgrade the Moka Hospital to a local and regional referral centre.

Summary/Objectives:

We have set two major objectives for our missions in Mauritius concerning cataract surgery:
1 – The training of the surgical staff towards modern cataract operation techniques, i.e. phakoemulsification, is mandatory. We have emphasised progression in the organisation of the operating theatre and a move towards a specialisation of the operating theatre nursing staff. This will be accomplished only by dedicating operating theatres nursing staff for exclusively O.R. activities.
2 - The surgeons’ consultation should include less refraction for outpatient that could be more effectively performed by non surgical doctors. Another possibility would be to use the competence of private opticians of Mauritius for the refractions. Although there might be some resistance in learning phakoemulsification by part of the surgeons, there should be an incentive by positive actions to motivate surgeons to perform phakoemulsification on a higher scale. A period of about 2 years is indicated to move from extracapsular cataract to modern phakoemulsification.

Results:

The surgical transfer of competence for cataract surgery has started in January 2006 and was at its stage of initiation with teaching surgical techniques during one year. The next stage was progressive handover by the training team to local surgeons in a step by step approach during the surgical procedure during 2007. The waiting list has dropped from 3500 to 2500 within 4 months (reference: Medical Hospital Moka, 2008).

Lessons learned:

1 – The ophthalmic surgeon has to be mostly dedicated to his continual learning in modern cataract surgery. This better use of the specialist staff is the only possibility for Moka to catch up with the huge cataract waiting list.
2 – The total commitment of the whole medical team is essential to melt down the waiting list. Furthermore, new nurses should be trained for surgical activities only.
3 – The strategy for the Moka Hospital should turn towards the organisation of modern facilities for cataract outpatient surgery: reception, nurses, transport and follow-up.

University Research for Developing Minimally Invasive Surgery Can Provide Treatment Where It Was Once Not Available

Author(s): C. Sanger*1, L. R. David1
Affiliation(s): 1Plastic and Reconstructive Surgery, Wake Forest University, Winston-Salem, USA
Keywords: Craniofacial surgery, international educational exchange, minimally invasive surgery, scientific advances
Background:

When one or more of the cranial sutures fuse before the brain has had time to grow it is called craniosynostosis. Normal brain growth relies on the major cranial sutures remaining open until the late adolescent and adult years. Craniosynostosis affects as many as 5 infants in 10,000 and can lead to serious irreversible damage if not corrected in a timely manner. In the mid 1900s, surgeons began to perform complex cranial vault remodelling to release the intracranial pressure. This was done by removing the entire calvaria, expanding the bone segments and replacing them with plates and screws. The operation lasted the entire day necessitated blood transfusions and long hospitalizations. From that time to the turn of the century no significant progress was made to offer a safer procedure for the treatment of craniosynostosis. We now have a minimally invasive technique that provides infants treatment without the high risks previously encountered.

Summary/Objectives:

In 1998, the craniofacial centre in Sweden began to perform spring mediated cranioplasty where only the prematurely fused suture was removed and a stainless steel spring was placed at the craniectomy site. The spring provided lateral distraction which provided brain growth and skull shape normalization. The procedure was new but the early results were profound. In July 2000, Wake Forest University launched the research project to study the technique. Institutional Board Review (IRB) approval was obtained for the animal study which then transitioned to the prospective infant study. The study resulted in Food and Drug Administration (FDA) approval for spring mediated cranioplasty for the treatment of craniosynostosis. A single craniectomy is performed at the site of premature fusion. The inexpensive stainless steel spring is placed at the craniectomy site which causes lateral expansion slowly over three to five months. This prevents premature re-fusion without significant blood loss or pressure on the brain. The objective was to offer patients a safer procedure with no need for blood transfusions and significantly reduced hospitalizations.

Results:

We now have patients with seven years follow up and are excited with the sustained normalization of the skull shape and improvement in the intracranial pressure. The children no longer need blood transfusions and are able to return home after only one night in the hospital. We are now sharing this procedure with other countries and find it particularly beneficial for countries with limited technology and supportive services. Extensive cranial vault remodelling requires extensive equipment for monitoring the infants in the operating room and postoperatively. The safety and cost of blood transfusions required for traditional surgery often makes it impossible to offer to infants. Since spring mediated cranioplasty is comparatively much safer, it is now possible for treatment to be provided for patients that would otherwise not have any options available. The procedure has been performed in several countries around the world with successful results.

Lessons learned:

Surgeons from different countries are able to share ideas for improving patient treatments for complex deformities. Once institutionally approved studies have been performed the advances can be shared around the world to improve the lives of children worldwide.