We have profiled the non-acute surgical procedures performed in Mae La Refugee camp over May 2005 – April 2007. Excepting the dominance of sterilizations (approximately 60% of all procedures) the remaining operations are of a similar nature to that expected on a minor or general surgery list in an equally sized non-refugee community. The dominance of sterilizations is not unexpected given the unmet need in this area.
The profile highlights the need for routine minor operations: apart from sterilizations, mass excisions (particularly lipoma and cystic lesions) and hernia repair were in high demand. Within the gynaecological operations, intervention for uterine prolapse was prominent. Surgery for infection (abscesses in the “Other” category) was also common. Procedures for these indications are not necessarily complex, and as demonstrated here, can be carried out with minor complications and good outcome. While we could not find a report on complication rates for this type of mixed general surgery, it is anticipated that such a rate would be low, and similar to that which we have found given that this type of elective and pre-emptive surgery is generally not associated with many complications. However, under-reporting of complications may be due to recording errors, misattribution (e.g. not attributed to post-operative state) or by patients presenting to the other health facility in the camp (run by AMI). Finally, there were no recorded cases of complications related to anaesthesia.
The number of procedures conducted over two years was large, probably due to backlog and a policy of referring only acute cases. Aside from direct symptom relief and quality of life gains (e.g. from excision of large, debilitating masses) many of the procedures performed have additional long term benefits. Sterilization (with reduced subsequent risks of grand multigravidae complications such as post partum haemorrhage), hernia repair (reduced strangulation risk) and haemorroidectomy (reduced risks associated with blood transfusion) are a few examples of this.
In the context of healthcare in resource poor settings, surgery has been presumed to be an expensive intervention and largely sidelined for more prevalent and easily managed causes of mortality and morbidity (e.g. infectious diseases, reproductive health needs). Nonetheless, there is now increasing recognition that surgical conditions account for a significant proportion of global morbidity, estimated at 11%, and that this burden is disproportional to the developing world. Evidence is emerging that basic surgical care is cost-effective in terms of averting the loss of Disability Adjusted Life Years (DALYs)[15, 16]. However it must be borne in mind that this new evidence is from small hospitals catering to native populations, not from chronic refugee situations, and is generally biased in favour of acute, potentially life threatening surgical indications. Similarly, while evidence is mounting that the surgical needs of civilians in conflict situations are not primarily war-injury related, and that a substantial proportion is attributable to accidental injury and infection, this evidence is still confined to the “Emergent” phase of crisis. To our knowledge, our study is the first to specifically address non-acute surgery in the “Chronic” phase.
In the specific case of a chronic refugee situation, there are three, broad, possible solutions to managing non-acute surgical morbidity: 1) referral of cases to specialist surgical services (i.e. a District Hospital), 2) the use of visiting specialist surgeons to perform series of operations en bloc for specific indications, or 3) the use of a general surgeon, or some combination of these. It is cost-prohibitive to refer all non-acute surgical cases to secondary care. This leads to the current policy of referring only acute or urgent cases, while non-acute conditions remain largely unmanaged. The foreseeable problems with this approach are a large pool of unmanaged morbidity (as demonstrated) and the potential for conversion to acute complicated situations. However there is little data to support or refute the hypothesis that preventive surgery in this context (e.g. for uncomplicated hernia) will be cost-effective in reducing expensive, acute complications.
Conversely, the use of visiting specialist surgeons has been demonstrated to be a highly effective strategy in some situations; the most notable local example of this is the provision of cataract surgery along the Thai-Myanmar border. A visiting ophthalmologist performs cataract surgery during two-week blocks, two to three times a year with up to 600 procedures per annum. This program has been highly successful in reducing or reversing visual impairment in the refugee population. However, this success relies on several factors: long-term commitment and regular visits made by the team of volunteers, narrow indications for which the surgeons operate, a high level of local staff training to identify and pre-operatively counsel and prepare patients (prior to the arrival of the surgeons), good cooperation between the eye team and local health bodies, and no potential for acute conversion to a complicated condition. Additionally, prevalence of cataract is relatively high, contributing to the cost-efficiency of the program. It is difficult to apply this strategy for the range of conditions we have identified in our study – no indication other than cataract is of sufficient prevalence to justify a visiting specialist for that indication alone. Furthermore, there is a lack of trained staff to adequately identify and select patients outside the surgical window. Finally, some of the indications found here have the potential for conversion to acute situations with prolonged wait.
In the limited cost analysis that was possible for this data, the use of a general surgeon to perform a limited range of non-acute operations was most favourable. The in-house surgical service of Mae La Camp performed general surgery worth approximately 2,200,000 THB (75,000 USD) over a two year period, calculated using cost data for those procedures obtained from MSGH. Concurrent costs of the service were approximately 1,300,000 THB (43,000 USD), leading to a cost saving of approximately 900,000 THB (~32,000 USD) compared to if these cases were referred onwards. The estimated cost of the Acute Surgical Referrals to MSGH over 14 months (3,800,000 THB [130,000 USD]) is substantial. Approximately 350,000 THB (11,800 USD) of this total was attributable to ‘preventable’ referrals.
The calculations above are conservative because we were unable to obtain hospital cost data for some of the procedures performed in-camp; the value of these procedures has been excluded. Further, the beginning of the period over which ‘preventable’ referral costs are estimated is subsequent to the beginning of the surgical service by more than a year and it is likely that the acute complication (and therefore referral) rate was somewhat lower than prior to the institution of the service. Finally, running costs, particularly staffing cost, of the service are an overestimate. In the first instance, the surgeon and midwives were employed to perform an obstetric service; the general surgical service took a secondary role and therefore total staff costs cannot be attributed solely to the latter.
As discussed, a backlog of cases likely contributes to the high volume encountered here. It is possible that over time, the rate of new referrals would have diminished to, or reached a plateau at, a level where the in-house surgical service was no longer cost-effective but this trend was not observed in the time period. Conversely, as the service was not advertised – it relied mostly on word of mouth within the camp – it is probable that only a proportion of people with potential surgical problems presented; other patients would have never heard about the service. As the surgical service was terminated in 2007 (the surgeon left for another position), we have no further data with which to analyse these hypotheses. An option to extend the efficiency of a surgical service such as this might include pooling patient populations from multiple refugee camps, e.g. transporting patients to Mae La refugee camp from neighbouring camps in the same region. However this solution must be considered within the local context – logistical and security factors increase the complexity of transporting refugees (and staff, e.g. midwives) between sites in host nations, particularly along the Thai-Myanmar border.
In surgical care provision, adjunctive considerations include anaesthetic and operative complications and availability of adequate post-operative care. As noted above, we found an acceptably low rate of operative and post-operative complications, with no anaesthetic complications. Contributing factors to this a caseload of consisting of relatively minor procedures and a low threshold for exclusion of cases during pre-operative assessment. The latter was due to a lack of material and human resources to deal with complex cases, as well as relatively basic anaesthetic and resuscitation facilities. In terms of anaesthetic services and risk, midwives providing care were trained only in basic airway management. While this level of anaesthetic care is a cost effective solution adequate for simple, low risk procedures, it was considered inadequate for cases with a high risk of needing resuscitation. Anaesthetic care is therefore likely to be a limiting factor in any such surgical service. Furthermore, lack of blood products limits the scope of feasible procedures.
A final consideration is the justification for elective surgical service provision in chronic refugee situations, given that such services are often lacking at District or Regional level in many low income countries. Refugee situations experience factors unique to them – chief amongst these is reduced freedom of movement. Logistical and security factors impede movement (and transport) of refugees within host nations – these factors influence referral decision making. The population is often reliant entirely on the profile of services provided by NGOs and has no freedom of choice per se. While a comparatively sized population in a low income country will likely suffer from under capacity for elective surgery, these populations have (albeit often limited) recourse via referral either laterally to other providers or upward to Regional centres.
When considered together: the burden of non-acute surgical morbidity, the cost to NGOs of referral (both non-acute cases and acute conversions) and the relatively low cost of operating a simple minor surgical service within the camp, the argument for such a service appears positive. Further research is required into feasibility of the delivery of such surgical care: with increasing specialisation in surgery, the availability of general surgeons with requisite skills and experience to manage this range of conditions may be in question. Moreover, while some of the conditions managed in-house in our context are presumed to be beyond the capacity of a non-surgeon physician, surgical task shifting has been deployed safely and cost-effectively elsewhere[18, 19]; further study is required as to what extent such strategies can be employed in chronic refugee situations.