Surgical outreach program in poor rural Nigerian communities

Introduction: The majority of the world’s population resides in rural areas without access to basic surgical care. Taraba State in North-Eastern Nigeria consists of rural communities where approximately 90% of the State’s population resides. Methods: This was a prospective study of patients whose surgical conditions were treated during surgical outreach program in rural North-Eastern Nigeria communities between February 2008 and July 2009. Results: A total of 802 patients had 903 procedures due to the co-existence of multiple pathologies in 97 patients (12.1%). There were 506 males (63.1%) providing a male to female ratio of 1.7:1. Ages ranged between one month and 91 years (mean 35.2±18.8 SD). Hernia repair 404 (44.7%), hydrocelectomy±orchidectomy 133 (14.7%), lumps excision 143 (15.8%) and appendicectomy 66 (7.3%) were the most frequent procedures. The surgical conditions were frequently long in duration and huge in size. The duration of goitres ranged from 2 to 28 years (10.3±7.4) and 4 to 42 years (15±13.9) in patients with cleft lip and palate. The procedures were performed under spinal, general and local anaesthesia in 7.6%, 34.3% and 58.2% of patients, respectively. No mortality was recorded but the complications encountered included: surgical site infection 46 (5.1%), scrotal haematoma and oedema 6 (0.7%), haemorrhage 3 (0.3%) and partial wound dehiscence 3 (0.3%).


Introduction
Surgically amenable conditions' substantial contribution to the global burden of disease makes access to surgery indispensable to realising the UN's Millennium Development Goals 1 .Conditions for which surgical interventions prevent major disability or death are expected to rise 2 .It is estimated that approximately 11% of the global disease burden that consists of miscellaneous but treatable surgical conditions is often neglected 3,4 .Most of those bearing this disease burden reside in poor rural communities with depressed infrastructure 3,5 .Inadequate surgical access leads to preventable disability and death in these communities 6 .
Financial deprivation and social barriers often impede the access of rural populations to urban healthcare services 4 .Meeting their surgical needs requires an equitable healthcare delivery system that eliminates prevailing barriers.Roads in very poor condition, long travel distances, lack of basic infrastructure, underutilisation of available resources and poor organisation are barriers that make rural patients likely to present late with advanced disease or to fall victim to 'quacks' 1,3 .
The provision of surgical services in the locality of rural dwellers reduces inconvenience and expense, and overcomes several barriers to accessing care 7 .An account is presented of such a service offered through an outreach program conducted over 14 weeks among the rural populace of North-Eastern Nigeria.

Program description
The programs were conducted in 11 general or district hospitals in the community.The communities were informed of the outreach by radio broadcast and pre-outreach visits paid to the community leaders.During the pre-outreach visits, personnel from assigned health facilities and local volunteers were educated on what would be required of them and how to perform their duties.An outreach session from 08.00 to 17.00 daily was available for 7-14 days at a particular location.The first days of every outreach were dedicated to the familiarisation of local and visiting teams, set up, further training of staff, and patient screening.
The visiting team consisted of specialist doctors, general-duty doctors, nurses, laboratory scientists, anaesthetists and students drawn from a pool of verified volunteers who were constantly available to the program.The team was usually accommodated in a location within 2 hours road travel of the designated project hospital.Overall team activities were co-ordinated from a regional headquarters camp located in the state capital at PHI national headquarters.
In the days penultimate to team departure only minor procedures were performed, and after the program intervention the logistics unit of the visiting team usually remained for 4-5 days in the community to treat patients who had post-surgical complications.The trained local personnel were instructed about the identification and appropriate referral of those with long-term complications.

Patients
Patients were screened by a doctor on the day before their operation for the following investigations, and to obtain informed consent.All patients had a haemoglobin estimation and urinalysis.Investigations such as ultrasonography, blood grouping and electrolyte measurement were performed selectively.Where required, blood was pre-screened and crossed-matched locally from consented donors (usually the patients' relatives).

Discussion
Nigeria is the most populous Black nation with a population of 140 million.According to the 2006 census the majority of this population resides in a rural area.Health care is provided in Nigeria by both private and public hospitals with over 80% located in the metropolitan area 8 .Public healthcare services are concurrently provided at tertiary, secondary and primary levels by federal, state and local governments, respectively 9 .The provision of surgical services at the district level is mainly from individual state government secondary hospitals because the local government-run Primary Health Centres (PHC) are staffed by paramedics and focus on preventive care 9 .
Taraba State has a predominantly rural population (11.6% of population in the four major towns) located within the mountain ranges that border the Cameroon Republic in North-Eastern Nigeria.It has a population of 2.3 million, a land mass of 54 473 km 2 , population density of 27.2/km 2 and annual growth rate of 3.1%, according to the 2006 census.The state's two tertiary hospitals (Federal Medical Centre and Specialist Hospital) are located in the capital Jalingo.At the time of this report, there were only 22 doctors in the Taraba State health service, covering its 14 public hospitals including the Specialist Hospital in the state capital.This is a common scenario in rural low-income nations and fails to meet the WHO recommendation of one doctor for 1000 inhabitants per annum.Globally, only approximately 3.5% of the estimated 234.2 million major surgical procedures performed each year occur in resource-poor nations; however, 73.6% occur in wealthy nations that represent only 30% of the world's population 10 .
During the rural surgical outreach reported, a total of 802 patients received an operation; however, due to the presence of multiple surgical conditions in 97 patients (12.1%), 903 procedures were performed.The diverse surgical conditions treated ranged from hernias to hydroceles, congenital anomalies, goitres, lumps, injuries and obstetric complications.A successful rural surgeon must therefore have wide surgical experience and be able to respond to lifethreatening emergencies.
Patients aged 20-40 years constituted 328 (40.9%) of the group treated.Among these young adults it is estimated that unaddressed surgical conditions would cause 20% of deaths and 10% overall deaths 5 .Those aged 60 years and older comprised 106 (13.2%) of the group treated.Elderly people comprise a large and increasing proportion of rural dwellers, are impoverished and can be expected to increase surgical demands and hospital admissions in the near future 11,12 .If unaddressed, old-age-related deaths can be expected to account for 75% of future mortality in low-resource nations 12 .Children are not exempt from low rural access to surgical care and represented 152 (16.8%) of the treated group.Uncorrected childhood surgical conditions such as cleft lip/palate may stigmatise a child at crucial periods in their lives, and the children of poor, rural households are also vulnerable to severe malnutrition, a greater disease gradient, erratic immunisation and high mortality, as reported from Uganda 13 .
The patients reported here were mainly subsistence farmers, traders, artisans or unemployed and this reflects the low socio-economic status of the rural population, who also lack reliable health insurance.In a previous survey only approximately 4% of rural respondents had their medical expenses covered by their employers 8 .Rather than merely focusing on the technical aspects of surgery, rural health care must be comprehensively delivered to meet cultural values, and social needs and expectations, all of which are strong factors influencing treatment compliance and patients' healthseeking behaviour 3,14 .
Hernia, the most common condition treated, is highly prevalent in resource-low nations due to poverty.In Africa, the yearly incidence of hernia reaches approximately 175 per 100 000 but only approximately 14.3% of inguinal hernias are repaired, despite the demonstrated benefits of elective hernia repair in reducing mortality and morbidity from bowel obstruction, strangulation and fistulation 15 .Few rural dwellers are able to take time off work for hernia repair at a distant hospital 16 .Likewise, hydrocele is the most common clinical manifestation of lymphatic filariasis in males; the majority of the over 120 million people affected live in poor, rural nations and suffer severe disability and dysfunction 9 .Due to a lack of surgical treatment, rural dwellers risk bacterial infection, infertility, hepatitis, HIV and the recurrence of symptoms following treatment by traditional healers.
Appendicitis, the most common acute abdominal surgical condition, involves increased morbidity, cost and hospital stay when complicated.The perforation rate is higher among rural than urban patients due to a delay in accessing care in urban centres and from inter-hospital transfer 17 .Prompt surgical intervention reduces both the mortality of appendicitis and the of perforation following nonoperative treatment 18 .
Emergencies and treatment of surgical complications constitute the bulk of surgical activity in developing nations 18 .The surgeons in this report performed 94 emergency procedures (10.4%), including acute abdomen from bowel obstruction, acute appendicitis, prolonged obstructed labour, injuries and septic complications.Without surgical and obstetrical services, approximately 10% of the population die from injury, and 5% of pregnancies result in maternal death 5 .Vesico-vaginal fistula (VVF), a devastating condition that leads to social isolation, marital disharmony, divorce and severe psychological trauma following prolonged, obstructed labour in developing nations is worse among rural patients due to unsupervised or poorly supervised home delivery and delayed referrals by 'quacks' 19 .The misery of VVF is compounded by distressing morbidities such as rectovaginal fistula, foot drop, anaemia, pelvic infection and infertility.While simple cases could be repaired effectively by trained general or gynecological surgeons, the skills and experience of expert fistula surgeons are required for complex cases.Staged operations for such complex fistulas were avoided by the careful patient selection of a fistula surgeon 19 .Ruptured uterus in two grand-multipara, managed with uterine repair and bilateral tubal ligation, is a marker for lack of preventive health services and essential services in the community.Sadly, the number of rural women who die without reaching urban facilities is usually unquantified.
The surgical conditions observed in these rural communities were very large in size and frequently of long duration.The mean duration of 10.3 years for goitre (range 2-28 years) and 15 years for cleft lip/palate (range 4-42 years) are markers of the long waiting times for surgery.Huge hydroceles with gross testicular pressure atrophy warranted hydrocelectomy with orchidectomy in seven patients.Beside the higher mortality from surgical complications, large hydroceles carry the risk of impotence and infertility.Other large lesions included hernia, fibroids, and lumps that interfered with normal life, employment and/or mobility (Figs 2,3).Anaesthesia remains a major constraint to the provision of essential surgical services in resource-low nations due to shortages of trained personnel, equipment, supplies and suboptimal drug storage facilities 20 .During surgical outreaches, pre-operative anaesthesia assessment must employ skilled clinical judgement to ensure patient safety 21 .The surgeons in this project relied on LA and spinal anaesthesia for surgical procedures in 65.8% of patients.Local anaesthesia was utilised in hernia repair, hydrocelectomy, excision of lumps and thyroidectomy in 58.2% of patients, while spinal anaesthesia was used in the 7.6% of patients who had lower abdominal, limb or cutaneous lesions where LA was not feasible.Both anaesthetic techniques are cheap and effective methods that require less rigorous monitoring.Hence, in low-income countries where anaesthetic drugs and resources are scarce, much surgical morbidity and mortality could be prevented using these simple but safe approaches 20 .
As is shown in this report, a surgical specialist outreach program can fast track the provision of surgical care to a large number of patients and overcome obstacles to quality health care at the district level.In rural, low-income nations with mid-level surgical care providers or non-specialists keen for surgical experience, such a program also provides an opportunity to improve the skills and knowledge of local surgeons.For this reason local surgeons, nurses, paramedics, and students from district hospitals were include in the outreaches.An outreach also accomplishes more with personnel proficient in dealing with local disease conditions, and who are accustomed to the culture, beliefs and traditions of the local community.Finally, the transmission of surgical expertise and knowledge in this way integrates protocols for effective and appropriate patient follow up.

Conclusion
In low-resource rural communities, the wide spectrum of frequently multiple and long-standing surgical conditions can be treated successfully using the focused approach described in this report.Where anaesthetists are not readily available, much can still be achieved under LA.A remarkable reduction in the surgical disease burden in these rural communities is feasible with well-organised surgical outreaches that also strengthen local capacity.Collective responses and the unanimous actions of both surgeons and health policy-makers can make this expertise more widely available to assist in establishing crucial, self-sustaining and autonomous surgical rural health care.

Figure 1 :
Figure 1: Patients' age group and gender distribution.

Figure 2 :
Figure 2: Preoperative gross umbilical hernia in a 32 year old woman.

Figure 3 :
Figure 3: The woman after surgical repair of the gross umbilical hernia.
This prospective study was conducted between February 2008 and July 2009 in rural Taraba State, North-Eastern Nigeria, where approximately 90% of the State's population resides.Patients were treated for surgical conditions at 11 different locations during a 14 week surgical outreach program sponsored by the TY Danjuma Foundation in collaboration with Pro Health International (PHI).Pro Health International, a non-governmental organisation usually partners with state and local governments, private organizations or individuals for sponsorship of such outreach programs.While PHI provides the personnel, equipment and medical consumables, the partnering body provides the funds and health facility to be used.The surgical care is provided at no cost to patients.

Table 1 :
Spectrum of surgical procedures performed in the outreach BTL, Bilateral tubal ligation; ERPC, evacuation of retained products of conception; POP, plaster of paris.† Includes breast, keloids, dermoid and sebaceous lumps

Table 2 :
Number of patients and surgical pathologies treated in the outreach