The burden of musculoskeletal disease in the developing world is enormous and growing due to increased road traffic accidents and other forms of injury. Compounding this burden is a severe shortage of orthopaedic surgeons in low- and middle-income countries (LMICs). In such settings, surgical intervention has traditionally been reserved for emergency or salvage care; elective procedures are performed infrequently, and the burden of neglected injuries continues to rise. From the patient’s perspective, care facilities may not be available or accessible due to poor roads and infrastructure, and if they are, care is typically not affordable. Without a steady supply of intellectual and material resources (e.g., orthopaedic implants), musculoskeletal care delivery is often not timely or even possible.
There has been growing interest from surgeons in wealthy nations to assist colleagues in LMICs across all surgical subspecialties. Unfortunately, compared to other specialties, orthopaedic surgery is resource-intensive, requiring expensive implants, cumbersome equipment, and a great deal of instrumentation; most orthopaedic procedures cannot be performed effectively with just a scalpel and sutures. Several organizations and nonprofits have created opportunities for orthopaedic surgeons to volunteer during seven- to 10-day trips to provide care in austere environments across the globe.
Although volunteer teams have the best intentions, serious, unanticipated consequences can result from short-term, one-off volunteer surgical missions, some of which may go unrecognized by visiting teams. After a volunteer trip for “blitz surgery,” which involves executing as many procedures as possible over a short time, several patients may develop postoperative complications. Local surgeons and teams may be left with unsolvable scenarios due to local systemic limitations. Patients typically present during such trips for free care from “international expert” surgeons; after the surgeons’ departure, the patients may be less willing to pay for care from “local” surgeons. After well-intentioned volunteer trips, local surgical capacity remains unchanged. The current state of affairs begs the question, “Is there a more sustainable solution to make a difference in the developing world?”
In order to provide a more sustainable solution for patients and improve local surgical capacity, a few organizations have fostered strong relationships with local institutions. The organizations send teams and material resources more frequently and incorporate teaching and bidirectional knowledge transfer in their missions.
Bridging the gap
Before proposing a solution, it is critical to understand from local surgeons what the most significant barriers are to delivering effective care in their own environments. Since 2014, the University of Pennsylvania has forged a strong relationship with the Department of Orthopaedics at Kilimanjaro Christian Medical Centre (KCMC), a large, tertiary referral, teaching center in Moshi, Tanzania. Orthopaedic surgeons at KCMC defined the following barriers to musculoskeletal care delivery: (1) a deficit in surgical capacity, both with respect to the number of operating spaces and the number of skilled healthcare providers available to address the current burden of disease; (2) a lack of patients able to pay for care, with most wealthy patients traveling internationally for care; and (3) an inability to obtain a steady supply of implants—local providers currently depend upon monthly implant donations.
But there is a novel, sustainable, collaborative solution to the previously defined problem. With the assistance of key multidisciplinary partnerships such as GE Healthcare, the Wharton School of Business, and the Leonard Davis Institute of Economics, Global Orthopaedics proposes building an Orthopaedic Center of Excellence on the KCMC campus in Moshi, Tanzania, for the Department of Orthopaedic Surgery at KCMC. The center will be populated year-round by foreign thought leaders, who will serve in an educational capacity. With the University of Pennsylvania at the center of the effort, the collaboration is framed to include the following:
- An additional 25 major academic institutions, each donating two weeks per year, will provide care to Tanzanian patients in collaboration with local partners; the partnership will be centered on the development of local surgical capacity.
- Each institution will sign out a service every two weeks to the next visiting institution.
- The clinical focus will be on pediatric orthopaedics, orthopaedic trauma, adult reconstruction (hip and knee), and plastic/hand surgery (soft-tissue rearrangement and vascular surgery).
- Each team will include four Board-certified surgeons, four senior-level residents/fellows, and 10 to 12 additional team members (e.g., nurses, therapists, scrub technicians, nurse anesthetists, internists, anesthesiologists, etc.).
- Each team will utilize predetermined clinical care protocols for the delivery of orthopaedic care.
- Over the course of eight to 10 years, the goal is to reduce foreign surgeon involvement in direct care delivery and to populate the hospital entirely with newly trained East African surgeons.
- In the interim, the current orthopaedic staff, residents, and medical students have online access to the University of Pennsylvania Biomedical Library, as well as online video resources through the Department of Orthopaedic Surgery at the University of Pennsylvania.
- The collaboration is founded on education at every level of the system. The local team receives a salary from the Tanzanian government, and the new system doesn’t impede on this; the visiting teams are volunteers.
- Colleagues in Moshi invite this strong collaboration with the University of Pennsylvania, as the new system allows them to address the issues of surgical capacity (both space and workforce), patients’ inability to routinely pay for care, and a steady supply of orthopaedic implants.
- The Orthopaedic Center of Excellence at KCMC is being designed for international teams to collaborate, operate, and cross-pollinate with the local orthopaedic team and train the next generation of orthopaedic surgeons in East Africa.
In most developing nations, top-notch health care is available only to the top of the pyramid, who can afford such services, but a majority of the population exists at the bottom of the pyramid. This new model is based on delivering democratized orthopaedic care, granting the same quality of care regardless of a patient’s ability to pay. Patients will be subclassified into various packages for care provision based on their ability to pay, but the differences between packages are based on amenities, not quality of surgical or postoperative care. The plan is to retain patients who currently have the ability to pay but travel great distances outside of Tanzania for their care to offset costs for patients who have fewer financial resources. In addition to providing excellent, culturally sensitive, democratized orthopaedic care, this mission focuses on medical student and resident education to help build the next generation of African surgeons trained in the latest surgical techniques and on the latest orthopaedic equipment.
To improve reliable access to implants, a critical partnership has been forged with an implant company based in Rajkot, India, to supply a full complement of orthopaedic implants in Tanzania at a significantly discounted rate. The local distributorship will be able to maintain a complete set of instruments at KCMC, as well as restock implant inventory based on utilization.
At this stage, the financial model, business plan, pitch book, and final structural design have been completed and vetted by partner organizations. All 25 initial teams have been identified, and alternate team members and additional volunteer staff are being finalized (Fig. 1). The goal is to have the proposed Orthopaedic Center of Excellence open in the summer of 2021.
Visit www.globalortho.org to make a donation, remain updated on the initiative’s progress, and connect with the team if you are interested in volunteering.
Neil P. Sheth, MD, FAAOS, is chief of orthopaedic surgery at Pennsylvania Hospital, an assistant professor in the Department of Orthopaedic Surgery at the University of Pennsylvania in Philadelphia, and director of Global Orthopaedics.
Ajay Premkumar, MD, MPH, is an orthopaedic surgery resident in the Department of Orthopaedic Surgery at the Hospital for Special Surgery in New York City.
Others who contributed to the article include Honest Massawe, MD; Rogers Temu, MD; Anthony Pallangyo, MD; Elifuraha Maya, MD; Celine Levy, MBA; Mack Hardaker, BS, MS; Praveen Rajaguru, BS, MPH; and Sireesh Ramesh.