The Many Faces of Safe Surgery

Sep 20, 2017 · 7 min read

In our society, we say ‘the team has done this,’ and we don’t usually appreciate the individuals. But it is the individuals who each make the difference.

— Dr. Andualem Deneke Beyene

Interviewed by Cole Bingham

The surgical team at Lemlem Karl Hospital in the Tigray region of Ethiopia.

In September, during the UN General Assembly, Jhpiego, the GE Foundation, the G4 Alliance and others will be discussing the global movement to strengthen surgical care for the 5 billion who currently lack it. Ethiopia is taking a leading role in ensuring its citizens have access to surgical services they need. Earlier his month, I had the privilege to talk with Dr. Andualem Deneke Beyene, the Secretary General of the Surgical Society of Ethiopia. Dr. Andualem is a surgeon and public health expert with decades of experience in the Ethiopian health system. What follows is our conversation, edited for clarity.

Cole Bingham: Thanks so much for taking the time to talk with us — Ethiopia has made really remarkable strides in surgical care. I wonder if you could talk about how you first got started in surgery, and what you do now?

Dr. Andualem: I work for the Addis Ababa University, College of Health Sciences, and for the Surgical Society of Ethiopia and other organizations — like Jhpiego — as a mentor and advisor. Before I became a surgical resident, I worked in a regional health bureau as a family health expert, and I got insight on public health. So when I went to study surgery and became a surgeon, I was always craving a time when public health and surgery would meet.

Cole: And that time is now?

Dr. Andualem: It has always been my belief that if we think of the hospital without surgery practices — it is just a clinic, it’s not a hospital. My country understands this, and decided that surgery is a public health problem, and now the time has come that we can make a difference at scale.

I am sure that we will make a difference in the coming years in surgery. It won’t just be at a single hospital or a single medical center. It will be across Ethiopia.

Cole: You’re a mentor with SafeSurgery2020 — a collaboration of foundations, nonprofits, educational institutions and local governments that want to make surgery safe, affordable and accessible across the world. The project has been going on for more than 2 years; what kind of difference are you seeing in hospitals supported by the project?

Dr. Andualem: Within a very short period of time that we started this project, we really found an achievement difference. That struck me. When I visited the supported hospitals, they were achieving more not because we brought in more supplies, but because the leaders responded to our call.

Cole: What do you mean by that? What was the call?

Dr. Andualem: Well, for example, there are two leaders that stand out, both of whom are CEOs of their hospitals. Kide — he’s the CEO of Maichew Hospital. And he had data that told him that for years, the hospital’s newborn mortality rate had lingered at 3 percent. Now, that’s not specifically something that we told him needed to change — but as a leader, he decided that was too high, it was too many newborn deaths. So he assigned a higher number of nurses to the unit. He brought focus and accountability, and made sure to celebrate the unit’s successes regularly. Today, their newborn mortality rate is less than 1 percent, because he stepped in as a leader and made change happen.

Teame, he was in the opposite situation. His hospital is known to be one of the best in the region. But they didn’t have any data on surgical site infections. His team thought the rate of infections was low, but there were no numbers to support their claim. So he implemented a data collection strategy, and empowered his team to get the numbers. It alerted the hospital to a big problem — too many people were getting infections after surgery. Now he can act on the data.

Safe surgery isn’t just about surgeons. Hospital administrators play a critical role in ensuring that high-quality surgical care is accessible to all.

Cole: So you’re seeing these leaders identify their own problems, devise their own solutions and execute their own action plans. And we’re not telling them what to do — we’re building their capacity as leaders?

Dr. Andualem: Exactly — though it’s not always a process improvement. Goitom, for example, is a senior official at Mehony Hospital. He knew his staff had the ability to perform cesarean sections, but they were constantly referring women elsewhere because they didn’t have a transformer or a backup generator, and the staff feared the power going off in the middle of a c-section — can you imagine? So Goitom worked incredibly hard to convince his district’s politicians to give Mehony Hospital the only available transformer in the district, as well as a backup generator. The month before he received the transformer, the hospital referred 17 mothers onto other facilities for c-sections. The next month, they only referred one. This is a significant achievement, and it’s nothing we gave or funded — it was because he took the lead.

Cole: What about non-administrative staff — the health care providers themselves. How are they taking the lead to make surgery safer?

SafeSurgery2020 aims to bring surgical care to many living in remote areas. Everyone, from the general surgeon to the laundresses and cleaners, have a critical role to play.

Dr. Andualem: There are so many, but one who stands out is Dr. Kumneger, at Alamata Hospital. He is a formally trained surgeon, and has been at the hospital for more than a decade. And you have to understand, he is very well-respected; he could have transferred to a more prestigious hospital in the capital, but he’s never left Alamata.

He comes into work at 5:00 or 6:00 a.m. every morning, 3 hours before his peers at other hospitals would typically arrive. So he’s doing more surgeries, and it shows — the surgical volume at Alamata is higher than at other hospitals. But not only that, he also brings lunch in for his team, paid for out of his own pocket. He eats with them, and it builds camaraderie. He could have done things in a more formal way. He could have transferred to a bigger hospital. But for 10 years, he’s gone the extra mile to help his team and improve his hospital.

Cole: Do you have a favorite story that illustrates resourcefulness of team members?

Dr. Andualem: Yes, although it’s not what you’d expect. Hadush is an emergency surgical officer. His responsibility, traditionally, starts with the patient. But in his hospital, they did not have a backup generator, and they were afraid to depend on electricity, for fear of losing it mid-surgery. So one evening, he frantically called his district politician, and he said that there was a mother in his facility who needs a c-section, and because they don’t have a backup generator, they can’t risk operating.

He said she’s going to die.

Then he gave the politician a solution: there was a small generator in one of the nearby communities, not being used. So of course, the politician arranged it all and Hadush’s hospital quickly received the small generator, and Hadush could then rely on electricity during surgery.

Cole: All this because Hadush, the surgical officer, took the initiative.

More than 100 000 maternal deaths might be averted by timely intervention, and increased access to caesarean delivery reduces neonatal mortality by 30–70%. (Lancet, 2015)

Dr. Andualem: Right, but what was surprising about the story is that there wasn’t really a mother in the hospital that evening … but there could have been.

Cole: And I understand that this is not the only hospital where lack of supplies and infrastructure can have a devastating impact.

Dr. Andualem: When we invest in leaders who take the initiative to identify and solve their own problems, we build resilient systems. I hope, in the coming years, that we will convince other organizations to invest in surgery and to be a part of this international effort.

I am sure the future is bright as we work together.


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