There are few surgeons who are as passionate as Atul Gawande about improving the desperate state of surgery in the poorest parts of the world. I met him a few years back at the launch of his bestselling book, “Complications”. He is a surgeon, academic, author, public health guru and heads Safe Surgery Saves Lives, a WHO group, formed to improve patient safety within surgical specialities. You cannot help but be impressed by the simplicity and the far-reaching consequences of research coming from the group. For example, a 19-point surgical checklist was introduced in eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) for 1 year. Use of the checklist reduced death rate from 1.5% to 0.8% and reduced complications occurring in hospital from 11% to 7%.

The Lancet Online First includes the latest study from Gawande’s group. Apparently, 11% of the world's disability-adjusted life years (a measure of the disability caused by diseases) are due to diseases that are often treated with surgery, whether coronary artery bypass graft surgery in coronary heart disease, carotid surgery in the setting of stroke, cancer surgery, or trauma surgery following road traffic accidents. There are huge global inequalities in terms of the operations performed. Out of 234 million surgical procedures done every year, the richest third of the world’s population has three-quarters of the operations, whereas the poorest third has only 4%. The latest study looks at how much of that inequality is due to two integral parts of surgery. One is the operating theatre, and the other is pulse oximetry, the simple process by which a patient’s blood oxygen levels are monitored during an operation. The study used WHO data from 769 hospitals in 92 countries. Importantly there were no differences in patients, health systems or wealth between countries that did have data about operating theatres and pulse oximetry and those which did not. Therefore, these factors are unlikely to be confounders.

The results make sombre reading. Rich countries like the UK had at least 14 operating theatres per 100 000 people, while all poor regions of the world (accounting for more than 2 billion people, or a third of the world’s population) had fewer than two operating theatres per 100 000 people. This is in spite of having more surgically treated diseases per head than do rich countries. As the authors state, “People in such regions are effectively without access to surgical care”. The fact that over half of operating theatres in sub-Saharan Africa did not have the facility to measure oxygen levels and therefore could not monitor a patient’s breathing during anaesthetic is horrifying and is probably the tip of the iceberg in terms of lack of other essential surgical and anaesthetic equipment. Whilst showing these inequalities does not solve them, it does the vital job of highlighting where global health initiatives need to focus.

Over the last few days, the Prime Minister has led a large, high-powered delegation to India promoting greater collaboration between the UK and India in areas as diverse as health and science to trade and climate change and education. Vince Cable, the Business Secretary, was very impressed by what he saw in the Narayana Health City (one of the largest medical facilities in the world) in Bangalore (one of the top four technological hubs in the world). The Narayana Hospitals (between Bangalore and Kolkata) currently have 5000 beds in India and aim to have 30,000 beds in the next 5 years in India. In terms of cardiac care they are doing some amazing work there against the odds: treating patients from 73 countries with complex heart disease and doing the largest number of heart surgeries on children in the world. No wonder Vince Cable was impressed.

In countries such as India, patients can have a massive array of procedures from cataract surgery to coronary artery bypass graft surgery at a fraction of the cost in the Western world. The massive growth of the private health sector in India has increased efficiency and quality. In the UK, medical tourism has been authorised for certain procedures as a way of reducing costs and waiting lists, and increasing consumer choice. This trend is set to increase after the European Court of Justice established the right of European citizens to seek treatment abroad if they are entitled to it in their own country but have suffered an unreasonable delay. There are now a massive number of medical tourism companies which will organise all aspects of healthcare abroad and a relaxing holiday afterwards. The Confederation of Indian Industry estimated that 150,000 medical tourists came to India in 2005, and the health care market, which includes health insurance, is set to expand by 2012 from US$22.2 billion (5.2% of GDP) to US$69 billion (8.5% of GDP).

There is another side to this coin. India has probably the worst health and wealth inequalities of any country in the world. The new “multidimensional poverty index” designed by the Oxford Poverty and Human Development Initiative showed that Bihar, the poorest state in India, has more poor people (95 million) living there than do nine of ten poorest countries in Africa. In 2001, India had only 35 well-equipped centres for modern diagnosis and treatment, mostly located in the six metropolitan cities; this is grossly inadequate for a vast country with an immense population such as India. The Narayana Hospitals currently do 12% of all cardiac surgery in India. That probably tells us that across the population there is not that much heart surgery going on.

The problem of inadequate resources is compounded by the fact that despite being one of the world’s major sources of medical staffing, the number of physicians per 100,000 population is less than 50. To plug the “brain drain”, the Indian government is starting a shortened, rural medical training programme to train and retain doctors in the poorest areas of the country. This is an innovative scheme which other developing countries will be watching closely.

So what can we learn from Indian healthcare? Firstly, sophisticated, world-class healthcare can be performed at a fraction of the cost of healthcare in the US and the UK with equal if not superior quality in the private sector of developing countries. Secondly, private healthcare does not at all reflect the health of the nation and often broadens health inequalities. On this point, the Narayana Hospitals are truly remarkable as they incorporate many societal initiatives such as microfinance and education. Thirdly, as flows of patients, doctors, and resources across country borders are all likely to increase in the future, improvements in the planning of our own healthcare resources and the way we interact with other countries (such as India) are a necessity.

The Oxford Society of Medicine, tonight at St Catherine’s College held an event to discuss how best to support medical education in the Occupied Palestinian Territory. ‘What is it that inspires Doctors to work in the Occupied Territories,’ was the theme of the night

The key themes of the night were:
1 How have health services in the Occupied Palestinian Territory suffered as a result of their isolation and fragmentation, and how can this be resolved?
2 What are the current barriers to education in the Occupied Palestinian Territory, and how can these be addressed?
3 What is the potential for increasing research capacities the Occupied Palestinian Territory?
4 Does the UK have special responsibility to help medical education in the Occupied Palestinian Territory? And if so, how can this be achieved?

The panel gave ten minute talks: Dr Nick Dudley - Consultant Endocrine Surgeon at the Department of Surgery, John Radcliffe Hospital started the night by talking about ‘Facts on the ground.’ In 1946 Palestinian land occupation was 94%, by 2010 this figure is 10% and there are currently 4.7 million refugees. Over 100 UN resolutions have been contravened in the occupation. The impact is to deprive Palestinians of their livelihood, water resources are scarce, and the construction of the settlements justifies the wall and the road matrix, which is currently 450 km in length. Oh and it’s electrified. On the ground this means 39% of Palestinians are encircled or separated from their land, 34% live outside the wall. ‘Passing check points is deeply humiliating.’

Could the stats be any worse, well 70% of small businesses have closed in the last ten years whilst 132 pupils have been killed on their way to school, 12,000 homes destroyed since 1967. In Gaza, 80% of the population exist on £2 dollars a day whilst the blockade prevents exports and viable business.

Dr Richard Horton - Editor-in-chief of The Lancet - talked about his trip there earlier this year, ‘What could we do to help?’ One of the pressing needs is to systematically train researchers, training Phds, supporting Masters Students. Supporting the Universities to better understand the Palestinian case, understand the needs, and focus on supporting human rights. ‘There is a lot we can do’ says Richard Horton.
Checkpoints are like going through ‘Cattle gates, deeply humiliating.’

Prof. Colin Green - Professor of Surgical Science at UCL and UNESCO Chair of Cryobiology with the Ukraine Academy of Science – opened with ‘It isn’t all doom and gloom, and there are beacons of light.’ A group of us in 1989 started thinking about starting a Medical School, which took its first students in 1994.

Starting with 32 students, near Jerusalem (50% were women) students undertook a seven year course. The first students graduated in 2001, 23 of them. In a short space of time they have grown to 800 students in four different campuses. I think he’s right, and He is determined to go on working with the schools. The weaknesses are the specialities only one pathologist in the whole of the West Bank. ‘Family practice is very poor,’ it seems everyone goes to the hospital: ‘We need champions of primary care,’ enthused Prof Green. In addition, it seems what is also desperately missing is psychiatrists. What are we to do?

Mr Nick Maynard - Consultant Upper Gastro-Intestinal Surgeon at the John Radcliffe Hospital, talked about his recent trip to Palestine. Three years ago he knew nothing about the region, but since this time He has learnt a lot from the medical students, whilst teaching out there. It took medical student at one of his teaching sessions 3 and half hours to get there. ‘There is never a better time for doctors to go there and teach.’

‘On that note’ what should we be doing?

Got any answers?