Ebola - What Has Surgery Got To Do With It?

In July, the World Health Organization (WHO) declared Ebola an international emergency. The fear of this deadly disease and the urgent need for international aid should be taken very seriously. However, deaths from Ebola are not an isolated phenomenon, but a symptom of something more complex. The effects of this terrible disease expose and exacerbate preexisting weaknesses in the health system, causing further suffering and deaths.

Ebola is not a new disease. It is a virus that was detected in 1976, but this microbe only caught the world’s attention in the West Africa outbreak in 2014-2016, where more than 28,000 people caught the disease and almost half of them lost their lives. The American College of Surgeons proposed a protocol to guide practitioners on how to perform safe procedures for Ebola patients in 2014. Unfortunately, WHO and CDC have both failed to endorse it, leading to continued uncertainties pertaining to safe surgical care during outbreaks.

As Ebola raged through western Africa in the previous outbreak, the already fragile health systems broke down causing pervasive collateral damage. Health facilities closed and doctors were quarantined or exiled due to fear of the disease. Public faith in the healthcare system dwindled, leading to increasing reluctance to seek medical help when needed. In Sierra Leone, two of the eight surgeons at the country’s only tertiary hospital passed away due to the virus. With a growing disease burden and thinning workforce, the healthcare system became increasingly strained and surgical care suffered as a result. The rates of surgical procedures in Sierra Leone reached a record-low of 3% of the estimated need.

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Infectious outbreaks arise in the context of poverty, conflicts and weak health systems. A 2014 study showed that a substantial part of the death toll during the 2016 outbreak was due to failure of an already frail health system rather than the viral disease. Patients died primarily from treatable surgical conditions such as appendicitis, trauma and complicated labor. Surgical conditions persist in times of infectious outbreaks yet tend to be forgotten as the epidemic monopolizes human resources, financing and attention. Preexisting inabilities to adequately treat patients with such conditions are exposed and further aggravated when the system is put under the pressure of the contagious disease. Hence, long-term strengthening of surgical care capacity is a key measure to minimize the damage when the next epidemic strikes and to prevent future outbreaks.

More than just preventing millions of deaths from surgically treatable causes, strengthening essential surgical care creates a resilient health system that can endure crises such as disease outbreaks. Resilience means that we are fit to cope with challenges that we are faced with and that we learn from previous experiences to adopt improved strategies for the future. A robust surgical system is key during an epidemic and its aftermath, ensuring uninterrupted delivery of essential healthcare, social cohesion and the minimization of human and financial losses. A health system lacking resilience is likely to have disorder and overcrowding when an epidemic occurs. This endangers the safety of the hospitals, especially emergency wards, as these may become hubs for infection transmission. Similarly, the public perception of the healthcare system is likely to be destabilized, leading to increased risks of patients delaying seeking care in the case of suspected infection or other condition.

The optimal way of building resilience depends on the context as it should respond to existing vulnerabilities in the current system. Thus, preventable morbidity and mortality due to inadequate surgical care has to be met with advancement of essential health infrastructure such as surgical services. Such an approach will provide the co-benefit of safeguarding health for all, even in times unplagued by epidemics. A first step in this direction is to implement the guidelines for surgery during Ebola outbreaks as proposed by the American College of Surgeons.

Ebola has to be treated as the crisis that it is. However, we need to see the context in which Ebola occurs and address the underlying issue of weak health systems and inadequate surgical care. An advanced public health response needs to be accompanied by long-term strategies for surgical systems strengthening. Only then can we prevent the loss of thousands of lives when the next outbreak strikes.

Written by Lotta Velin, @VelinLotta

Edited by Jacquelyn Corley, @JacquelynCorley