Teaching brain surgery in Africa: Compelling book reveals neglected area of health

Dilan Ellegala (left), the central character in "A Surgeon in the Village," supervising brain surgery in Tanzania. Photo: Tony Bartelme

This was originally published on Global Health TV on August 3, 2017.

“In early 2010 Bill Hawkins, then executive editor of the Post and Courier in Charleston, South Carolina, told me, ‘I met this crazy brain surgeon who opened a guy’s head with a wire saw in Africa. Check him out. Maybe we’ll send you to Tanzania.’ Not many reporters get such an invitation, but thanks to Bill, I was soon on my way.’”

So writes Tony Bartelme in “A Surgeon in the Village: An American Doctor Teaches Brain Surgery in Africa,” an informative and highly engaging book about a neglected area of global health – the dearth of surgeons in low- and middle-income countries. The book, published in March, is based on hundreds of hours of interviews that the author conducted in the U.S. and during five trips to Tanzania between 2010 and 2015.

When I started reading this book, I approached it as an obligation – something I had to do to inform myself, and possibly my readers, about an area of global health I knew nothing about.

But to my great surprise, I not only found it informative, I enjoyed it. The book is written in short chapters and in more of a novelistic style than most pieces of non-fiction. What I thought would be a chore turned into a pleasure. Perhaps that is because Bartelme is an experienced journalist who knows how to tell a good yarn.

Bartelme tells the story of Dilan Ellegala, a Sri Lankan-born American, who ignores his father’s advice to become a family doctor (“You should have a life”) and becomes a brain surgeon because he had "fallen in love with the brain" (in medical school, he kept a brain in a glass jar in his room so he could pull it out, hold it up to the light and study it).

He goes to Haydom Lutheran Hospital in a remote, rural part of Tanzania for six months of medical sabbatical. He finds out that Tanzania, a country of 42 million people, has just three brain surgeons in the country, all of them in Dar es Salaam.

One day a farmer came to the hospital, who had bashed his head in a fall. He was in serious condition but Ellegala knew he could save him if he could get inside the man’s head to stop the bleeding. But he had no way of opening his skull due to a lack of a Gigli saw (which goes for twenty bucks in the United States).

He told himself that the farmer was going to die. “Nothing I can do. Let it go,” he told himself. So he went for a run in the bush to clear his mind and encountered a man cutting a tree limb with a wire saw. He bought the saw off the man, rushed back to the hospital and saved the man’s life.

Ellegala quickly realizes that despite the well-intentioned efforts of rich country doctors who travel to developing countries on short-term assignments, this approach will never address the underlying problem in these countries – the lack of surgeons.

Apart from a small number of global health leaders, Bartelme writes, there was no public outcry over the shortage of surgeons at the time: “None of the U.N. Millennium Development Goals mentioned the shortage of surgeons and other skilled health care workers. The United Nations’ 356-page update in 2005 didn’t use the words surgery or surgeons once.”

Yet 17 million people die every year because of the shortage of surgeons, more than AIDS, malaria and tuberculosis combined. In 2006, Haile Debas, the director of the University of California Global Health Institute, and some colleagues published a study that showed 11 percent of the world’s global burden of diseases could be averted or treated with surgery.

In 2015, the Lancet Commission on Global Surgery produced the report Global Surgery 2030, with five key messages:

• 1.5 billion people lack access to safe affordable surgical and anesthesia care.
• 143 million additional surgical procedures are needed each year to save lives and prevent disability.
• 33 million individuals face catastrophic health expenditure due to payment for surgery and anesthesia each year.
• Investment in surgical and anesthesia services is affordable, saves lives and promotes economic growth.
• Surgery is an indivisible, indispensable part of health care.

The Commission found that 5 billion people worldwide are unable to reach surgical services, and over half the global population cannot access the treatment they need should they, for example, hemorrhage after childbirth, suffer a burn or develop cancer. And access to care is even worse for those in low- and middle-income countries.

Ellegala came to believe that the only way to solve this problem in a sustainable way was to use Western surgeons not to do the surgery, but to teach Tanzanians to do it themselves – and not doctors – who are also in short supply -- but lower level health cadres. He calls this approach “train-forward.” That is what Ellegala does with Emmanuel Mayegga, an assistant medical officer, who had never done any kind of surgery before, let alone brain surgery. But it works, and Mayegga becomes a credible brain surgeon.

Before Ellegala returns to the U.S., he tells Mayegga he must teach someone else brain surgery. So he trains Emmanuel Nuwas who, in turn, trains another. “Train-forward” in action.

Eventually, Ellegala, his wife Carin Hoek, a pediatrician from the Netherlands, and others create Madaktari Africa (Madaktari means “doctors” in Swahili) ”) — a group that sends hundreds of doctors around the world to serve as mentors and to create a sustainable new model for global health. Madaktari’s story is told here.

“A Surgeon in the Village” is an excellent read, even to non-global health aficionados, and sheds much-needed light on a neglected area of global health.

The Lancet Commission on Global Surgery has produced a report called Global Surgery 2030. The commission produced this report overview and this policy brief.