Scouting Surgeries, Healing the Margins

This article was written by Mike Kotsopoulos and republished from the Spring 2022 Harvard Otolaryngology Magazine

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For most people in the world, surgery has become a privilege, not a basic human right. According to the World Health Organization (WHO), five billion people live without access to safe, timely, and affordable surgical care. The situation is particularly dire in low- and middle-income nations—nine-out-of-10 people lack access to basic surgical services.

Doctor shortages, crumbling infrastructure, and inconsistent funding often confine surgical services to cities located hundreds of miles away from where care is desperately needed. The crisis looms larger than life in Nepal, where the Himalayas separate millions of people from the nation's capital, Kathmandu. Without a vehicle or alternative means of transportation, it can take days, or weeks, to reach the capital for even the most basic procedures.

"You can't just cruise to your surgeon's office on an interstate highway like you would in the United States or Europe," said David A. Shaye, MD, MPH, FACS, assistant professor of Otolaryngology–Head and Neck Surgery at Harvard Medical School and facial plastic and reconstructive surgeon at Mass Eye and Ear.

"The terrain is so challenging that a 50-mile journey can take weeks, with much of it on foot."

Working in collaboration with Nepalese plastic surgeon Shankar Man Rai, MS, of the Nepal Cleft and Burn Center in Kathmandu, Dr. Shaye investigated how to bring specialized cleft services to rural Nepal. Together, the doctors successfully shifted the screening process for cleft lip and palate repairs away from specialty-trained surgeons in Kathmandu to local scouts. None of these scouts had a formal education, yet knew how to navigate the treacherous Himalayan terrain by foot.

As reported in Facial Plastic Surgery & Aesthetic Medicine, the intervention of surgical scouts has led to a significant increase in surgeries for cleft lip and palate patients living in 22 of Nepal's most-remote districts. The study evaluated a practice called task shifting, or the redistribution of tasks among health care workers, in the context of the surgical screening process. How such tasks are shifted among surgical scouts may provide a novel blueprint for surgeons facing similar problems in areas with equally challenging geography.

Needless Morbidity From Cleft Lip and Palates

Experts report that cleft lip and palate anomalies occur in approximately one-in-700 births, making them the world's most common congenital craniofacial anomaly. Children with cleft palates, or a gap between the nasal cavity and the roof of the mouth, often experience air leaks into the nose, resulting in difficulty eating or delayed speech. Those with untreated cleft lips, or a divide in the upper lip, struggle to carry the psychological burden of the social stigma associated with a facial deformity in Nepal.

"There's a cultural belief that facial deformities are a sign of someone having committed a serious wrongdoing in a past life, which can bring immense shame to a family," said Dr. Rai. "We've seen parents abandon children in the jungle or leave them for dead on the side of the road. This has underscored the need for repairing these deformities."

According to Dr. Rai, only three specialty-trained plastic and reconstructive surgeons live outside Kathmandu. Many Nepalese surgeons struggle to live off low wages provided by hospitals, which prompts them to open private practices in large towns with high patient volumes. However, 80% of the 31 million people in Nepal live in isolated, rural districts four-to-nine days away from the closest tertiary surgical center, which makes cleft lip and palate surgical care extraordinarily inaccessible for the vast majority of the country.

In an attempt to decentralize care away from Kathmandu and large towns, Dr. Rai partnered with international aid groups Smile Train and ReSurge International to establish six mobile surgical centers in select districts. Both aid groups would fund the sites, and specialty-trained facial plastic and reconstructive surgeons who practiced in Kathmandu would arrive to perform cleft lip and palate procedures for the local population. However, underdeveloped Nepalese infrastructure often prevented word about the surgical camps from reaching patients in more remote districts.

"A bus can take you only so far in Nepal," Dr. Rai said. "Roads end long before surgeons have a chance to reach many villages, which means villagers might have no idea we even exist. We can't properly heal the marginalized without actually reaching the margins."

Blazing a Trail to Surgical Care

Task shifting is one common technique employed to relieve severe strains on a surgical workforce. The technique involves training nurses, technicians, and residents to perform basic procedures without a doctor. Although certain procedures, such as Cesarean sections, are straightforward enough to shift in high volumes, highly specialized procedures, such as cleft lip and palate repair, are not. These procedures are too complex and require too much training to shift at a moment's notice.

"Imagine trying to teach someone a crash course on how to repair a congenital facial defect and then sending them into the mountains?" Dr. Shaye said. "We'd be trying to cram 10 years of reconstructive specialty training into the span of a few days."

Instead of shifting the entirety of cleft lip and palate procedures, surgeons would need to break the procedures into simpler tasks. In partnership with the Nepal Cleft and Burn Center in Kathmandu and with the support of a grant from the Harvard Medical School Center for Global Health Delivery–Dubai, Drs. Shaye and Rai collaborated on an approach that would shift the screening process of these procedures to 44 non-medical Nepalese surgical scouts. Together, the surgeons collaborated on a five-day course to train these scouts on identifying and referring patients for surgery.

The surgical scouts would then rely on their own native topographical expertise to trek Nepal's most remote districts and find patients. Otherwise-healthy patients were referred to the six mobile surgical centers set up by Dr. Rai. These sites were located close enough for patients to reach in a matter of a few days, as opposed to the weeks-long trek it might normally take to reach Kathmandu. Only patients with complex comorbidities, such as airway concerns or cardiopulmonary conditions, were referred to Kathmandu for tertiary care.

According to the study published in Facial Plastic Surgery & Aesthetic Medicine, the surgical scouts correctly diagnosed 89% of the 139 patients examined, and correctly referred 82% of patients for cleft lip and palate procedures. As a result, the percentage of patients from remote districts who underwent cleft lip and palate repair increased significantly. With scout intervention, the percentage more than doubled, and would later quadruple when scouts assisted patients with transportation or accompaniment.

"As scouts see more and more patients over time, we expect their assessment skills to improve," Dr. Shaye said. "This would only increase the percentage of patients on the correct road to a life-altering procedure."

Bringing Scouts and Surgical Care to the World

Throughout his career, Dr. Shaye has traveled to Africa, Asia, and Central America to collaborate with surgeons on improving surgical care. His most recent efforts have moved away from the provision of surgery and pivoted towards teaching and investigating creative approaches to distributing care. While surgical scouts are one way of rethinking how patients are screened and identified for surgery, educating more doctors about these specialized procedures will ultimately decide the trajectory of the global surgical crisis.

Trauma, for example, is another enormous disease burden left largely untreated in Africa. According to the WHO, trauma has actually surpassed the combined mortality of tuberculosis, HIV, and malaria. With assistance from the Swiss AO Foundation, Dr. Shaye and a group of international colleagues have developed a facial trauma educational program focused on managing craniomaxillofacial trauma in low-income countries.

Under the Mass Eye and Ear Office of Global Surgery and Health, Dr. Shaye has also considered launching a Global Surgery Academy, where sponsored surgeons from low-income countries could spend time shadowing Mass Eye and Ear surgeons from every subspecialty. Surgeons would travel home with exposure to complex subspecialty otolaryngology care, while Mass Eye and Ear surgeons would learn of the complex challenges surgeons face worldwide.

"An education is the greatest gift we can give as surgeons,” Dr. Shaye said. “If our educational model can deliver care to the foot of Mount Everest, then there’s no reason why it can’t be replicated to eliminate barriers elsewhere in the world."

Learn more about the Department of Otolaryngology–Head and Neck Surgery at Mass Eye and Ear

Refer a patient to Mass Eye and Ear/Mass General Brigham