Category: Blog

Access to emergency and essential surgical services is an important element of an effective healthcare system. The attention given to global surgery has recently increased, and initiatives like the World Health Organization’s Resolution 68.15 have called on countries to make progress in providing safe surgical care. As a surgeon who lived and worked in a remote area without electricity and most surgical resources, and now as an Ethiopian state minister, I am aware of the significant burden placed on individuals and families due to a lack of access to surgical services in low-resource settings, and I am excited to be a part of the development of innovative solutions to address this problem. Hopefully, my story will support and inspire clinicians, researchers, leaders, and governmental and non-governmental organizations across Ethiopia and throughout the world, working to ensure equitable access to and quality surgical services for all. I was born and grew up in a small village in the rural part of Ethiopia, where access to good healthcare services was a distant dream for many people. I had the chance to witness countless deaths just due to a lack of access to essential health care, particularly emergency and essential surgical services. I shared the pain, lived with it, and lost many of my relatives and community members because of it. In this environment, I was inspired to pursue a career in medicine and eventually became a surgeon, determined to make a difference for the people of my home village. Figure 1. Merhabete Alemketema High School After finishing high school and two years of preparatory school in that poor village, I was fortunate enough to join one of the universities in the capital of Ethiopia, Addis Ababa University, which was an opportunity I never thought was possible at the time. During my internship at the medical school, every time a uterine rupture presented, the patients mostly came from rural areas after being referred, and upon their arrival, they were exhausted; some of them died on the roads. Amusingly, these patients were mostly from my village, Merhabete, where I was born and raised. This made me feel a profound connection to the suffering of these people, and I felt a strong sense of duty to help them in any way I could. Figure 2: Patient being carried to a health facility, where there are no roads or vehicles available. After graduating from university, I returned to the rural villages, whilst I could have been assigned to the capital city with better medical facilities and higher salaries, I chose to work in the rural villages, not just to provide better healthcare and improve access but also because I saw how much of a difference I could make. During this time, I began to understand the system challenges of providing surgical services in low-resource settings. The first challenge was a lack of human resources, as the village had no general surgery,  obstetrics, or anesthesia specialists, and I was only a general practitioner. As part of the solution, my nurse colleague and I took a three-month course in emergency anesthesia and surgery, respectively, and returned to work. These enabled us to perform emergency CS, hysterectomy, appendectomy, bowel resection, anastomosis, and trauma-related procedures, which are now called the Bellwether Procedures. At least pregnant women and people with severe injuries were spared having to travel 180 km by gravel road across deserts and steep cliffs to a nearby hospital, which would further complicate their situation. Figure 3: Gravel roads and bumpy roads Alem Ketema, 2017 The second challenge was the cultural norm of the community not visiting the health care facility early for medical care, often waiting too long to seek treatment. This was especially difficult for mothers who were forced to give birth at home with traditional birth attendants and considered going to the hospital a taboo, which resulted in life-threatening complications and came to the health facility when it was often too late. To combat these issues, the hospital staff worked diligently to develop a strong rapport with the local community by organizing education campaigns and programs. We also invited mothers treated at our facility to participate in promotional activities, and we met with birth attendants to address their concerns and ensure they referred mothers in need of medical attention earlier. All these efforts have increased the number of patients admitted to our hospital.  Figure 4: Alem Ketema Hospital, North Shewa, Amhara region, Ethiopia Despite the assistance we were receiving from the Menschen for Menschen program established by Dr Karl Heinz Boem, who was constantly donating and supporting this hospital with equipment, beginning with upgrading, and furnishing our hospital from a small health center, other challenges included insufficient funding and staffing levels, as well as a limited supply of some surgical equipment and blood products. We began contacting the Ministry of Health and regional health bureaus to address these issues while also attempting to use all preventive and treatment measures to help our patients with our limited resources. In such a situation, I worked for three years as an emergency officer and then I left the village to advance my education by specializing in obstetrics and gynecology. Following my specialty training, I returned to this community, and most challenges remained unresolved, and some had even worsened, though the community’s needs are increasing. People needing surgery could not be accommodated, so a substantial number of those cases were referred to the nearest hospital, located more than four hours away, where they also might be told to come back after a week or months. Often, I am asked to operate on brain tumors, which is not my area of expertise, because people think you can operate on anything if you open up an abdomen. This is the point at which I realized that I had to look beyond providing medical care and toward leadership to make a meaningful and lasting impact on these people’s lives that is not dependent on individual efforts. Figure 5: Surgical team in the OR