Medical emergencies occur every day all around the globe. A boy breaks his arm riding a bike. A young pregnant woman has obstructed labor. Appendicitis. In the developed world these problems create anxiety but are nearly always treated successfully with no long-term sequellae. In contrast, in the developing world, these conditions almost uniformly lead to long-term disability or death. The Lancet Commission on Global Surgery published a new report in April 2015, “Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.”The news is not good; despite dramatic advances lifting hundreds of millions of people out of poverty in recent decades, access to medical care (and particularly surgical care) is sadly lacking for most of the world’s population. Millions of people die each year from easily treatable problems. It is estimated that:
- 5 billion people lack access to surgical care
- Only 6% of operations occur in the poorest 1/3 of the world’s countries
- Over 140 million additional operations are needed each year in low and middle income countries to save lives and prevent disability.
The lack of access is complicated. Barriers include a lack of safe and equipped operating rooms, too few surgeons, too few anesthesiologists, and inadequate transportation. An important barrier that has only recently been included in evaluating access is the inability of poor people to pay for surgery even when it is available. This study emphasizes that surgery is an “indivisible, indispensable part of health care” and points out that surgical care is cost effective compared to other health interventions.
These are difficult problems that require focused, long-term support to develop the necessary infrastructure. Too much of the world’s efforts to provide surgery have come in the form of “camps” where expert teams appear for short-term, high-volume surgery. While these efforts can certainly change lives of individuals they usually do nothing to improve baseline conditions in the area (and in fact can even have a detrimental effect by undermining what services are available).
The International Continence Society has an interest in this problem through the Fistula Committee. Obstetric fistula is all but totally eliminated in the developed world through access to quality obstetric care, especially cesarean section. However, obstructed labor continues to be a major cause of death in the developing world. Those women who do survive are often left with total incontinence; this problem is much more difficult to fix than the common types of incontinence in wealthy societies. In addition, as maternal health improves, it is very likely that there will be an epidemic of more common stress incontinence and pelvic organ prolapse as women gain rights and access to care. These problems are simply “under the radar” now. The ICS Fistula Committee works with the Continence Promotion Committee and the Education Committee to provide educational materials that can make pregnant women aware of the risk so that they might know when they need to go to a hospital or medical center for help with a delivery and to make plans in advance for how they would do so. Indeed the Lancet report makes a very important statement about this – if a hospital provide facilities for emergency obstetric care, the ability to do a laparotomy and fix an open fracture then you have the ability to provide universal surgery for all. Thus, the work done within the Fistula Committee is part of this integral new direction. Other goals and activities of the Committee include:
Publishing a Textbook of Fistula Care—in progress
Providing a video library on all issues regarding fistula care including prevention strategies.
To establish criteria for Fistula “Centers of Excellence”, to promote collaboration with such centers and ICS members, to promote collaborative research among such centers.
Promote study and care of women who are deemed incurable due to severe injury
Promote scientific and clinical research into the problem of residual incontinence following successful primary repair of obstetric fistula
To coordinate with the Physiotherapy Committee to promote and define the role of physiotherapy in fistula care
To interact with other fistula professional bodies such as FIGO, PAUSA, SIU and WACS; and funders and research bodies, such as Engender Health (USAID) and the Fistula Foundation so that care and research is delivered efficiently and for the long-term.
The Fistula Committee welcome all members of ICS working with them and if you wish to be involved in any of the above activities please let them know through the ICS office.
Article by Chris Payne on behalf of the Fistula Committee