EIGHT YEARS OF OPERATION HERNIA

INTRODUCTION

Operation Hernia is a 100% volunteer organisation, currently with no overheads. It was initiated in 2005 By Andrew Kingsnorth & Chris Oppong with the help of the Plymouth-Takoradi link and has since formed collaborations with the European Hernia Society, the Operation GivingBack organisation of the American College of Surgeons and the American Hernia Society.  It is similar in concept to the successful humanitarian organisations that deliver surgery for single conditions such as obstetric fistula, cataract and maxillofacial disorders (cleft lip and palate).  In 2006 the British High Commission in Ghana donated money towards the establishment of a Hernia Treatment Centre in Takoradi which is visited by volunteer teams four times a year.  In 2008, a mission was initiated with Dr Yombo Awojobi at the Awojobi Clinic Eruwa (ACE), in Oyo State, Nigeria. A site visit by Andrew Kingsnorth to ACE in June 2009 was followed by two further missions that year to ACE.

Since 2005 over 90 missions have been accomplished worldwide. Teams of surgeons and anaesthetists have originated from 26 countries and more than 9,000 hernias have been treated. Our main assets are the time and expertise of our Volunteers who pay all their own expenses when on a mission.

The goal of each mission is to provide immediate capacity, and the aim is to provide training and sustainability. We adopt a lean (minimalist) approach (as opposed to the brigade method in which a large number of volunteers mimic the conditions in their home country) with small groups of surgeons and anaesthetists integrating with local personnel using locally available equipment.

LOCATIONS

Six additional sites have been used in Ghana at Carpenter, Dixcove, Cape Coast, Nalerigu, Ho and Bole.  Four sites have been used in Nigeria at Eruwa, Aliada, Okpoga and Abor Mbaise.  Other centres have been established in Cote d Ivoire (Abidjan), The Gambia (Farafenni), Mongolia (Ulaan Baatar and beyond), Ecuador (La Concordia), Moldova (Soroca), Malawi (Thyolo), Peru (Lima), Ukraine & Rwanda.  To this total of 21 locations at least two new locations (Brazil and Cambodia) are already lined up for 2013.
 

GLOBAL HEALTH CARE

One billion people worldwide are without healthcare and one billion have minimal access to healthcare. Sub-Saharan Africa has about 39,000 doctors but it is estimated by the World Health Organisation that 290,000 are needed. Fifty-seven countries worldwide are in a healthcare crisis of which 36 are in Sub-Saharan Africa.

Eleven percent of the global burden of disease can be treated by surgery. In rural Africa caesarean section and hernia are the commonest elective surgical procedures. However, both of these operations are carried out much less frequently than required with the result that obstructed labour causes mortality and obstetric fistula; neglected hernias cause mortality (from strangulation) and physical incapacity.  It has been estimated by the WHO that the poorest third of people in the world undergo only 3.5% of the annual estimated 234 surgical procedures.  Since hernias are so common this burden of neglect falls disproportionately on hernia sufferers.  Unlike many surgical procedures, a simple, cheap 30 minute hernia operation returns the patient to full health. The modern and very effective technique is to repair the hernia with mesh. In rural Africa mesh is not affordable, so the majority of hernias are stitched with higher complications, delayed, painful recovery and frequent recurrence of the hernia.

Barriers to adequate provision of surgical care in rural Africa include deficiencies in infrastructure, water supply, electricity and oxygen.  In most rural hospitals there is a dearth of equipment, and trained surgeons and anaesthetists are unwilling to be posted to these areas. Therefore only basic surgical interventions such abscess drainage and wound toilet are performed in rural hospitals. Surveys show that the average rural hospital in Africa performs only five operations per week of which two are emergent and only one or two per month are for hernia. 

The WHO has recognised the need to rollout surgery in the developing world and the World Bank has launched a clinical package but caesarean section is the only surgical intervention in this package. Proposed solutions include the unlikely scenario that Governments will provide well equipped hospitals with fully trained doctors, surgeons and nurses in the near future. However, such a concept is supported by the West African College of Surgeons and the College of Surgeons of East, Central and Southern Africa. In the short term humanitarian missions such as Operation Hernia will provide a stopgap.  This stopgap is likely to last for at least the next generation, and without interventions from outside agencies, countless untreated patients will continue to suffer.  Further short term solutions include task shifting to non-medically qualified personnel. 

Economists consider improving surgical capacity at district hospitals to be among the world s top priorities.  The World Health Organisation has recently provided a specific tool for quantifying surgical capacity.  This is the GIEESC to assess emergency and essential surgical care which measures such things as electricity supply, running water, oxygen, fuel, infrastructure, personnel and supplies.  In all rural communities in African countries the GIEESC has found severe limitations in all these areas.

INGUINAL HERNIAS

Hernias occur with a similar frequency in all s and are affected by ethnicity and occupation, with a slightly increased frequency in Africans.  The lifetime risk for hernia of men is 27% and for women 3%.  There are an estimated 6.3 million untreated inguinal hernias in sub-Saharan Africa. Operation Hernia has discovered that the prevalence in rural areas of Northern Ghana is more than 10 times the predicted level because of the near total neglect of hernia surgery for many years. This has resulted in many men suffering large incapacitating hernias which limit their daily activities.  Every African living in a remote village can tell a story about a relative or village member who died due to the untreated complications of a hernia. In rural areas more men suffer from hernia than suffer from HIV.

IMPROVING SURGICAL CARE

Operation Hernia upgrades infrastructure by purchasing generators, air conditioners, electrodiathermy machines, surgical instruments, gowns, drapes, autoclaves, drugs and supplies in order to furnish an environment for the delivery of high quality surgery.  In addition a hernia awareness campaign is conducted by local nursing personnel to recruit patients for each hernia mission.  There is considerable cost to the host hospital during the mission week, because of high surgical throughput including increased activity in the laundry and the sterilisation process with extra staff hours required.  Volunteers (in UK and Africa) put in many hours of administration prior to each mission to ensure that it runs smoothly.  Patients themselves are required to pay for preoperative blood tests and postoperative drugs for pain relief. This usually amounts to between $20-40.  Volunteers require to be screened and affirm their commitment to global standards of care . In addition their credentials and experience are evaluated by an Operation Hernia committee and applications are made for them to receive local medical licensing.  Trainees in the host country are required to register and provide a summary of their competence in hernia surgery, to ensure that they have the correct level of expertise on which to build and teach them mesh hernioplasty technique. Hands-on teaching is provided together with theoretical lectures covering anatomy and surgical technique. 

FRUGAL INNOVATION

To lower the cost of hernia surgery in rural Africa Operation Hernia has pioneered the use of mosquito net mesh to replace industry manufactured synthetic mesh, which is the current standard of care in developed countries. The cost of mosquito net is negligible; the cost of commercial mesh is about $30-40 per patient.  The mosquito net mesh was introduced by an Indian surgeon in 1996 and has been used in that country in many thousands of patients.  It was not widely known outside the Indian subcontinent until Andrew Kingsnorth made a chance discovery in 2006. The originator Dr Tongaonkar has since provided advice to Operation Hernia and attended the European Hernia Society in 2009 to present his data. To follow this up an important economic analysis was made by Operation Hernia with the assistance of the Business School of the John Hopkins Medical School in the United States. This used the WHO approved cost effectiveness tool, the Disability Adjusted Life Year (DALY).  A DALY represents the loss of one year of equivalent work that an individual could accomplish at full health.  Our studies indicated that a mosquito net mesh hernia repair averts 9.3 DALY s per person.  The cost of averting each DALY was very accurately calculated to be $12.88, which amounts to a total cost (9.3x12.88) of $120 per patient (for the surgery).  This cost per DALY compares favourably with that for treating a cataract ($9), basic immunisation ($10), malaria prevention and treatment ($24), anti retroviral therapy ($350 - $1500).  An editorial comment on the publication by the Operation Hernia team from the editor of the Archives of Surgery (a highly cited surgical journal) reads as follows: A fabulously clever, inexpensive and context appropriate way of treating surgical disease .

CONCLUSION

International humanitarian missions can make a significant contribution to surgical training in low income countries in Africa.

Andrew Kingsnorth, Chief Executive Operation Hernia, Consultant Surgeon, Honorary Professor of Surgery, Peninsula College of Medicine & Dentistry, Plymouth, UK.