IGHS Translates Evidence into Policy to Improve Global Surgery

By Jessica M. Scully

Catherine Juillard wasn’t sure what to expect in 2011 when she presented the results of a pilot study on injuries in Cameroon to a roomful of the country’s infectious disease experts. After hearing bafflement from her peers in the United States on why a surgeon was in public health, and why she was headed to Cameroon to study injuries rather than HIV, she thought she might be “scoffed at,” she said.

Instead, the experts were deeply grateful. “Everyone in the room had somebody who’d experienced severe injury in their family or their life, because it’s such a large problem” in the country, she said.

Doctors performing surgeryNow the director of UCSF’s Center for Global Surgical Studies, Juillard leads a team dedicated to reducing the once-overlooked but enormous global burden of injuries and other medical conditions that need surgical care. The center, housed at the Zuckerberg San Francisco General Hospital and Trauma Center, is building on Juillard’s relationships in Cameroon and the University’s long-standing connections within Uganda to understand the toll injuries take in these countries and reduce it.

Through the work of the center, staff, masters and medical students, and surgical residents from UCSF and around the world partner with physicians and health officials in Cameroon and Uganda to generate detailed evidence on injuries and to create trauma registries in local hospitals. Long-term, the center hopes its research findings can inform policy recommendations on how government agencies and other partners can improve the quality of surgical care and implement proven interventions to prevent injuries.

Until recently, surgery was largely overlooked in global health. Global health’s roots are in public health, and both have historically focused on individual diseases and infectious disease. But as infectious diseases have become more controlled, conditions treated by surgery, including chronic diseases and injuries, make up an increasing portion of the global health burden.

In 2010, an estimated 16.9 million people died from conditions needing surgical care, according to Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development, the report of the Lancet Commission on Global Surgery. This is more than four times the deaths from HIV/AIDS (1.46 million), tuberculosis (1.20 million), and malaria (1.17 million) combined, according to the report.

Making surgery more accessible globally isn’t a simple fix, Juillard said. It requires “more health system strengthening, which is a more complex solution than something nice and tidy like a vaccine,” she said.

That’s where Sara Fewer and the Institute for Global Health Sciences (IGHS) come in. What sets the center apart from others doing similar work is its multidisciplinary approach to this complex problem, Juillard said. Early in its history, the center began working with Fewer, a policy analyst at IGHS who co-leads the Global Health Group’s Evidence to Policy Initiative, as well as two health economists and a biostatistician.

“I’m hoping that since we have robust data and someone like Sara to deliver this information in a more compelling fashion, that we can have some real tangible and sustainable results,” she said.

Evidence from the Cameroon and Uganda projects will help the center’s work with partners in each country to strengthen the countries’ health care systems. An important part of this will be creating effective health policies. Just as dramatically reducing the deadly toll car accidents took on Americans meant passing legislation requiring seatbelts and child car seats, saving lives in these countries will require policies that fit each country’s circumstances.

Having robust evidence on the state of injury and surgical care in Cameroon and Uganda, and studies identifying effective interventions for each setting, is crucial for developing policy solutions, Fewer said. The center’s research provides “exactly the type of information decision-makers in these countries need to understand the gaps in surgical care, develop new policies and guidelines that improve quality and access, and mobilize sufficient financial resources to support effective interventions,” she said.

Thinking through the policy implications of the center’s work starts early on to understand the local policy and political landscape of injury and surgical care.  “Engaging local experts and decision-makers throughout the research process helps ensure the work is addressing real policy needs in the countries where we work, and that the evidence can be easily picked up and used by policymakers,” Fewer said, citing lessons from the center and other IGHS projects.

In Cameroon, road traffic injuries make up about 60% of all injuries presenting to the emergency room, Juillard said. Use of seatbelts and helmets, proven to prevent injuries or reduce their severity, are low at 26% and 5%, respectively, she noted.

Another issue in Cameroon is that many patients who are injured use both “Western” health care, and independent or traditional providers, such as bone setters, Juillard said.

“We initially thought that the patient would get injured and there would be a decision: choose the hospital or the bone setter and that the patient goes on the trajectory initially chosen.”

The reality is much more nuanced, she said. “Patients tend to float back and forth between the two systems depending on what they need and what resources are available. That has been a really interesting discovery, because that changes how we would try to optimize care for individual patients.”

It also has policy implications, Fewer said. Because independent or traditional providers often are not organized or part of professional networks, it’s difficult for governments to understand the scale of these services and to monitor and regulate the quality of care they provide, she said.

“It’s a huge policy finding that patients are using a mix of services, and it suggests that we can’t just focus on solutions for the public hospitals,” she said.

Knowing these facts gives the center opportunities to work with Cameroon’s Ministry of Health to design effective long-term strategies, at both the individual hospital level and at the national level, Juillard said. For example, getting people to use helmets and seatbelts would require not just legislation, but understanding barriers that prevent people from using them, “and how to create that change within a totally different cultural context,” Juillard said.

In addition to policy on a national level, Juillard said, there’s “policy with a little p,” a term she learned from Fewer. That’s policy at the local, or even the individual hospital, level.

For example, in Cameroon, trauma patients are most likely to die during initial resuscitation, Juillard said. Reducing that risk could include putting together a quality improvement committee at each hospital, going through the data on deaths with members, and coming up with an analysis of what happened and ways to change practices or design new policies to reduce the likelihood of deaths, she said.

“Figuring out how to organize hospital resources and the system of care within the hospital unit more effectively is an opportunity for local policy change,” she said.

“And through policy briefings, advocacy and other engagement strategies, the center’s evidence can help raise the priority of surgical care nationally and help shape national surgical plans,” said Fewer.