Clean water and surgery: Not “either” but “both”?

Is surgery beyond the reach of the world’s poor? And how do we reconcile the issues involved with increasing access to surgery with the widespread need for water and sanitation?



A case example inspired by Dr. Robert Riviello, trauma and acute care general surgeon at Brigham and Women’s Hospital, gave us some big questions to consider.

Dr. Riviello pairs his work at the Brigham with clinical and research interests in global health, where is aims to reduce disparities the expand surgical delivery for low-income populations by developing surgical workforce and surgical infrastructure in sub-Saharan Africa. And along with his impressive skill as a surgeon, he’s a compelling speaker, productive researcher, and great blogger.

One patient’s story. We reflected on a case that Robert described to students in past years. José was a patient who arrived at Lubango Evangelical Medical Center where Robert worked in 2006 and 2007. A lack of needed equipment and services, and the patient’s advanced state of disease, meant that José did not survive the effects of advanced typhoid, despite the work of Robert and his colleagues–a challenging surgical repair followed by many days in the hospital.

What was the cause of José’s tragic death? Hospitals need supplies, equipment, and medications, along with staff. They also need water and electricity. But José needed transportation from his village. And he would not have suffered the perforated ileum that necessitated his surgery if he hadn’t contracted typhoid. What if the rural health post had the correct medicines in stock when he first felt sick? Perhaps the right antibiotics would have cured him. And clean drinking water would have prevented his getting the disease. (In a past class discussion, we considered the link to primary care; see Where to Intervene).

So where is the high leverage intervention? Inefficiencies in the financing, management, and delivery medicines contribute to one set of constraints that we all agreed must be addressed. Hospitals need all the inputs required to deliver effective healthcare. And, we felt, water and sanitation need to be tackled. Are we doing enough to connect global health to the need for water and sanitation improvements?

Why water matters.  A 19-minute documentary shared by the National Academies’ Institute of Medicine explores the global water crisis and its staggering toll of some 14,000 quiet preventable deaths per day. Focusing on China, the Middle East, Africa, India, and the United States, Running Dry presents arguments for international cooperation on water issues, highlights some promising grassroots programs to improve access to safe water, and gives you some suggestions for your own action steps (source for this text via above link).

A 2009 IOM report is available online: Global Issues in Water, Sanitation, and Health: Workshop Summary.

Why surgery matters.  Now, there is still a huge need for surgery, a topic we’ll return to in the coming weeks. Paul Farmer and Jim Kim made the case in a brief 2008 paper, Surgery and Global Health: A View from Beyond the OR  and the topic was taken on a year ago in a Harvard symposium on surgery in global health.

And in a 2011 paper in the Bulletin of the World Health Organization, Adam Kushner (with whom we worked in 2008-09 on a project in Sierra Leone) and colleagues point out that there are reasons to be hopeful that the gap can be addressed: Surgery as a public health intervention: common misconceptions versus the truth. A study of the experience of Médecins Sans Frontières found outcomes to be good (Operative Mortality in Resource-Limited Settings, in Archives of Surgery, 2010) and underscored the value of systematic quality improvement programs in low-resource settings.

Want to learn more? For a primer on surgery as a global health issue, work through Unite For Sight’s online course on surgery in global health.

Can better management, business and logistics innovations, and political and policy shifts help deliver all of the above?  Here’s a question to ponder: is there a trap in arguing for one against the other? Maybe it’s not whether water, medicines, or surgery should come first. Can we figure out how to help deliver all?

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