The surgical care of the poor

The purpose of surgery is to heal the sick. What is the use of it if the sick cannot afford it? The rapid growth of the populations of many of our countries requires that we care for ever more people every year, on a health budget which is not only low to begin with, but is static, or in some countries is even declining in real terms. Despite this, our patients now know what surgery has to offer, so that their expectations increase steadily.

We easily forget just how poor some of them are. They are about fifty times poorer than patients in Europe or North America. Of the $2 to $5 per head per year that is available in many developing countries for all forms of health care, half or more is spent in the cities, so that only $1 a head, or even only a few cents are available in the rural areas for both hospital and health centre care. The per capita income in India is less than $100 a year, and in the rural areas where 80% of people live, the cash income is even lower than that. Estimates as to how much an Indian villager can spend on health care range from 36cents to $5 annually. It is however less the cost in cash which devastates his family, than the complete disruption of their earning power.

Fortunately, the kind of surgery we describe is remarkably cheap and cost-effective[md]compared with the high technology surgery of the industrial world. But it is not so cheap in terms of a villager's income. If you work in a government hospital, such funds as you have will be provided for you. If you work in a voluntary agency hospital, and your patients have to pay, and you really want to care for them, you will have to keep your costs low. Complicated methods can easily lead to rising costs, and so gradually drive the most needy away. Instead, your hospital may fill with richer patients, who could, if they wished, seek care in the towns. Care can indeed be very cheap. For example, one Indian hospital (Herbertpur, Uttar Pradesh, 1977) charges the equivalent of $2.50 a day, which includes everything except food, which the patient's relatives cook. In one district hospital (Chogoria in Kenya) two thirds of the running costs are met from the patient's fees, with charges of only Kshs 20/- ($1.5) a day, no operation costing more than Kshs. 250/- ($20).

PULLING A HOSPITAL ''OUT OF THE RED' Here is some advice from Tumutumu PCEA Hospital in Kenya which was able to turn a substantial deficit in its accounts into a surplus in two years. Try to make the containment of costs, or their reduction, an activity which all your staff share. They and you should know how much everything costs. If you can make your financial decisions by mutual consensus, they will be implemented. Form an action committee consisting of all the spending departments[md]the medical superintendant, the administrator, the matron, and the senior medical assistant. Meet weekly and pass all decisions involving money through this meeting. A good time to start holding such meetings is after some crisis has occurred, for example, being told to cut your budget by 40%. A crisis atmosphere makes people more co-operative, and more willing to change their ways.

Examine all funds coming into the hospital and all funds going out of it, scrutinize all bills and orders. Discuss demands from each department, and reject any unnecessary ones. Scrutinize all expenditure and expect to make some savings on almost everything. No single item is decisive, but collectively they make the big difference. Look at the large items first[md]salaries, transport, and food[md]even small percentage savings here will have a big overall effect. Look at your establishment figures. You may find that your hospital has got fat and that you should let it get a bit leaner by not recruiting after natural staff wastage. You may find that you have to return to the staffing ratios and technologies (such as making your own plaster bandages) of earlier years. For example, you will probably find that most patients with pneumonia can be treated without an X-ray and so can most extension fractures of the wrist.

These meetings will be critical. They will ensure the co- operation of the leaders of all sections of the hospital, who will transmit the sense of urgency to everyone else. They will also help to create an awareness of the economic implications of a decision, to establish priorities, and to ensure the continuation and extension of your economy drive. Follow up your decisions[md]someone must check that the fire is extinguished once the water is hot, or that the right weight of the right cabbages has been supplied. Make sure that the staff know how much money is running through their hands, and that the viability of the hospital depends on how they use dressing materials, gas, and equipment.

Money coming in is no less important than money going out. So try to keep your beds full. Work out a policy to reduce costs to the patient, and to make your services affordable to as many people as you can. Think about what they can pay, and be prepared to lower some charges. This manual is mostly derived from experience in Africa, India and Nepal. Valuable contributions to the surgical care of the poor have however been made in South America. Adolpho Velez Gil and others found that in Colombia three quarters of all the operations were simple enough to be done on outpatients with a single anaesthetist supervising two patients simultaneously in the same theatre, mostly using local and epidural methods, and adequately supported by assistants. Operating theatres were only used for 40% of working hours, surgeons only did 120 operations a year and ''physicians' only 18. Gil was therefore concerned to increase the utilization of theatres, and the surgical productivity of both surgeons and ''physicians'. Since most of the operations were simple what was required was more generalists and fewer specialists. Is this true for your situation too?

In most hospitals, services are limited less by resources than by motivation. So expect to be able to do much more, even with what little you think you have. The rest of this section, which is based on the papers listed below, shows what can be done, even when resources seem to be already stretched to their limit. If you think that checking the stores is not your responsibility, remember that it is critically important for the financial viability of the hospital, on which your whole surgical endeavour depends.

Gichero F, Kimunyu E, Kibuyna R, Spellmeier W, ''How we pulled Tumutumu Hospital out of the red'. An article which should have reached Tropical Doctor but never did.[-3] Satow S, ''The Technical Aspects of Small Hospital Surgery', 1977 Proceedings of a Symposium Held at the 19th Meeting of the International Federation of Surgical Colleges.[-3] Gill AV, Galarza MT, Guerrero R, de Velez GP, Peterson OL, and Bloom BL, ''Surgeons and operating rooms: underutilized resources', American Journal of Public Health 1983; 73(12)1361- 1364. Mr Printer. Please take in the ''not in series' Figure: ''I pronounce you man and dressing' somewhere here where we discuss economical dressings.

ECONOMICAL SURGERY STAFF Reduce staff to the bare minimum by not replacing unnecessary ones, and make sure they do a full day's work. Keep existing staff busy with additional duties. Junior staff are often willing to have more responsible jobs such as filing and typing, or even preparing intravenous fluids. Try to lay off consistantly dishonest and inefficent staff. Encourage punctuality. Employ inexpensive ungraded staff where you can, to relieve more expensive staff of routine tasks. Employ multipurpose workers, such as a laboratory technician who can take X-rays.

SAVINGS ON CONSUMABLE MATERIALS Dressings. If necessary, you can treat most wounds without dressings. Most clean closed surgical wounds don't need them. Use gauze and cotton wool economically. Don't make dressings larger than is necessary. Resterilize all dressings which have not been used. Use narrow strapping, and don't allow it to be used anywhere except on the human body. Wash gauze sponges, immerse them in saline to remove stains, dry them and resterilize them. If necessary cut up an old polyurethane foam mattress or cushion into small squares and use these as swabs and sponges. They absorb blood and can be resterilized. Cut up and sterilize old linen. Sterile toilet paper can be used as an alternative to swabs for some purposes.

Laparotomy pads (''lap pads'). Use a sewing machine to sew enough pieces of gauze 20[mu]25 cm together to make a 5 mm layer; attach a tape to one end, and when you operate attach a haemostat to the tape and leave this hanging out of the wound. Lap pads are a more convenient and economical way of washing and reusing gauze than using it as swabs, and can replace them for some purposes.

Dressing a wound dry uses many more dressings than treating it wet. So keep it wet with saline, which need not be sterile. Make this with ordinary salt and tap water. This is the basis of the saline method for burns (58.16).

If a wound is suitably sited to be immersed, as with the arm, leg, or buttocks, immerse it in saline for 3 hours twice a day. Put a leg in a bucket, an arm in a long arm bath, and let a patient with a buttock wound sit in in a hip bath.

If a wound is not suitably sited for immersion, cover it with a thin layer of gauze or bandage and keep it wet with saline from a jug (58.16). Renew the gauze or bandage once a day. This is more economical in dressings than treating it dry.

Disinfectants. Don't fill gallipots to the brim. Use cotton wool, not gauze for scrubbing the skin. Don't use disinfectant for the preliminary ''scrub' to remove dirt; use soap and water. One gallipot of disinfectant will then be enough to ''prep' the skin. You can use it all day[md]it is self sterilizing.

Disposable items. Avoid these and replace them by permanent equipment. If you buy plastic equipment which is intended to be thrown away, choose the kind which you can autoclave or boil. Recycle everything you possibly can, and try to throw nothing away. Buy the kind of gloves you can resterilize 3 or 4 times. Resharpen needles and scalpel blades.

Use nylon syringes, such as the French KIGLISS pattern, which you can sterilize indefinitely, and which have a rubber ring to seal the plunger which you can purchase separately. Don't use disposable urine bags; instead, use bottles and tubing from old intravenous sets.

Catheters and cannulae. Use simpler rubber catheters instead of more expensive Foley catheters; if you want to leave them in, secure them with strapping. Use steel intravenous cannulae instead of plastic ones.

Intravenous fluids. Make your own for one fifteenth of the price of the commercial ones (A Appendix A). Where possible, use rectal rather than intravenous fluids (A 15.5). These are not suitable for rehydrating patients, but they may be adequate for maintenance.

If intravenous fluids are scarce, for postoperative patients who have had major gastrointesinal or other surgery, tie two pieces of ordinary intravenous disposable tube together. Insert them as a nasogastric tube with one tube in the stomach for suction, and the other in the distal duodenum or jejunum for feeding. In this way you will greatly reduce your need for intravenous fluid.

Oxygen is only necessary for such indications as pulmonary oedema, asthma and shock, and not for comatose or moribund patients. If it is used for patients with no hope of survival, relatives may come to believe that it is used to kill them!

Drugs. Use cheaper drugs instead of expensive ones. For curettage of the uterus use pethidine with diazepam instead of ketamine; use aminophylline instead of salbutamol, aspirin instead of paracetamol, nitrofurantoin instead of ampicillin for urinary tract infections, and morphine instead of pethidine for many applications. Look carefully at the prices you pay for drugs.

Sutures. Where possible, use surgical suture material bought in bulk on reels, or use nylon fishing line (4.6). Only use atraumatic sutures when they are absolutely necessary. With more expensive suture materials, use continuous sutures rather than interrupted ones. Buy reels instead of packs. The application of warm moist gauze packs to a bleeding surface will halve the number of bleeding vessels that you need to tie. You can tie those that persist with sewing cotton for almost nothing.

Scrubbing up Use ordinary soap not special fluids.

SAVING KITCHEN SUPPLIES Find the cheapest supplier and buy at the right season. Find out if buying in the market may be better. Watch tenders carefully, change suppliers when necessary, and insist on good quality. Don't let them supply you with old, rotten, or small potatoes. Buy boneless meat. Use powdered milk instead of whole milk. Adjust the number of meals cooked to the bed state. Give high protein diets only on genuine indications. Reduce waste. Fill plates moderately and vary helpings according to the appetites of both patients and staff. Keep pigs and chickens to feed on waste.

ENERGY SAVINGS Petrol or diesel. Diesel vehicles are cheaper to run. Use the smallest and most economical vehicle for a given job and fill it full. Keep logbooks and use vehicles for hospital journeys only. Drive at economical speeds and use moderate engine revolutions in all gears. Use public transport wherever possible. Encourage a style of driving that is considerate for the vehicle, especially when carrying heavy loads on bad roads.

Gas. Put lids on pots. Reduce the flames when the pot has boiled. Use pressure cookers. Soak beans overnight. Control cooking times.

Electricity. Reduce lighting to the minimum. Use fluorescent tubes instead of bulbs. Reduce hot baths to the minimum. Have one central hot water tap, from which the staff fetch water in buckets[md]if they do not object too much!

Solar energy. Solar lighting is more practical than solar heating, because of the smaller amount of energy needed.

Washing. Use the timers to set minimum times for washing and spin drying carefully. Avoid tumble dryers unless the climate is very wet; they use much electricity.

OTHER SAVINGS Use the space fully on all case sheets, use paper on both sides. Make your own forms with a stencil. Minimize the use of paper for internal correspondence. Use scrap paper for messages.

Don't use so much detergent that it causes foaming in the laundry and when scrubbing floors.

Register private calls, and make a 25% surcharge. Avoid long distance calls in favour of letters.

Control all items that could be used in private homes, including torch batteries, soap, matches, pens, toilet paper, female pads, food and medicines.

Keep a pair of tubes of epoxy resin. It is suprising what you will be able to mend.