Nurses as Surgeons: Expanding Roles in Sub-Saharan Africa

Heads are turning and the countries across the globe are paying greater attention to the lack of proper surgical services in developing countries. In these parts of the world, surgical intervention can significantly reduce the mortality rates caused by injury and obstetrics.

Surgery, in the United States or Canada, is understood to be expensive and complex. However, many surgical procedures can be dealt with in a cost-effective manner without the need for specialized staff and equipment. The main barrier facing the healthcare and surgical fields in developing countries is the shortage of trained health workers.

According to the World Health Organization's health report in 2006, Africa accounts for 24% of the global disease burden but only 3% of the global health workforce. The reasons for this shortage of health workers are evident in the poor salaries and working conditions. Undoubtedly, these problems lead to staff attrition and turnover, a reduced level of international funding, and an inadequate supply of medical schools in the regions. Of equal, if not greater importance, is the brain drain of the health staff and workers to countries that are able to provide better working conditions and resources. The brain drain and shortage of specialized medical staff is of particular concern for the positions of surgeons and anesthesiologists.

Compare the following stats:

- East Africa has 0.25 fully trained surgeons per 100,000 persons

- The United States has 5.69 fully trained surgeons per 100,000 persons

There's no clear picture for the immediate future. It is unknown what the minimum number of surgeons required will be to ensure proper surgical procedures in sub-Saharan Africa. As such, alternate strategies need to be devised. It is one thing for international experts and agencies to pour funds into the regions to develop surgical camps and specialist support programs. However, of greater reach and breadth is the mobilization of non-physician clinicians (NPCs) to perform surgical tasks. This method provides a shift in responsibilities from surgeons and anesthesiologists to non-specialists, providing an opportunity for basic surgical care to reach the most at-risk and rural communities in the region.

In the United States, many individuals resist the concept of NPCs, believing surgery to be a highly-specialized field requiring years of training that cannot be properly transferred over a shortened period of time.

With NPCs coming from the local area, they tend to understand the local cultures and traditions far better than visiting physicians and surgeons, allowing them to relate to their patients and the community population. Research has shown that NPCs are not only cost-effective because of their lower wages and shorter training periods, but also safe. Almost half of all countries in sub-Saharan Africa use NPCs to perform minor surgical cases. In Tanzania and Mozambique, 84% and 92% respectively, of obstetrics/gynecology cases are performed by NPCs.

The capacity to support international staff and surgeons is not yet existent in most countries in sub-Saharan Africa. Coming from North America, it is easy for one to argue that ethical standards are ignored and a lower standard of healthcare is offered to these individuals.

Turn that thought around and explore it from the other point of view. Then, one is then left to ask:

"In countries where the human resource capacity in the healthcare field is below par, is it morally ethical to refuse human beings the right to basic life-saving surgical tasks that can be just as successfully performed by non-specialists as they can by specialized surgeons?"

It may be a lower standard of surgical care than most people are used to appreciating in North America, but it is better than no surgical care whatsoever. Every country needs to start from some platform, and it appears this is the most feasible and promising option for several countries in sub-Saharan Africa. With local non-physician clinicians performing the tasks of surgeons and anesthesiologists, clinics and hospitals are on their way to providing basic life-saving surgeries to some of sub-Saharan Africa's most at-risk and rural peoples.

Reference Article: Chu K, Rosseel P, Gielis P, Ford N, 2009 Surgical Task Shifting in Sub-Saharan Africa. PLoS Med 6(5): e1000078. doi:10.1371/journal.pmed.1000078

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed....