Scalpel solidarity: surgery in Palestine In 2009, The Lancet Palestine Series called for increased international collaboration with Palestinian health professionals. David Holmes reports on how a group of UK surgeons are playing their part.
www.thelancet.com Vol 377 June 18, 2011
As surgeons in the UK, the Kincaids both completed the BSSC. “It was the very basis of our training”, recalls Magdalena. “Equipping junior surgical trainees with good solid basic skills such as haemostasis, putting two bits of bowel together, incising the abdomen correctly so you don’t
“Many of these skills are especially crucial for surgical trainees to master in the occupied territory, where ambulances are often made to wait for hours at checkpoints.” burst the bowel when you come in. These are all parts of the course”, she explains. Many of these skills are especially crucial for surgical trainees to master in the occupied Palestinian territory, where ambulances are often made to wait for hours at checkpoints. So, armed with nothing but their enthusiasm, the Kincaids resolved to take the BSSC to the occupied Palestinian territory. What followed were months of “incredibly tedious but very necessary behind-the-scenes work” to secure the necessary sponsorship to fund the course. Instrumental to getting the idea oﬀ the ground were the links that the Kincaids established with the Juzoor Foundation for Health and Social Development (a Palestinian non-governmental organisation based in Jerusalem) and the UN Relief and Works Agency for Palestinian Refugees (UNRWA), both of which wrote letters to the RCSE in support of the Kincaid’s request that the college teach the BSSC in the occupied Palestinian territory. Links that the Kincaids hope will be exploited by other surgical colleges in future. By September, 2010, the Kincaids had approval from the College, a team
of faculty volunteers to teach the course (all of whom paid for all their own travel), and enough sponsorship to get everything they needed for the 16 training stations (including a full laparoscopic training kit) shipped to Jerusalem from as far aﬁeld as Dubai. All that was left was to negotiate Ben Gurion airport with an array of home-made abdominal incision kits, and buy up all the sheep and cow bowel they could ﬁnd. For the Palestinian candidates trying to get to the course, things were almost as complicated. As Dina Nasser, health adviser at the Juzoor Foundation, explains, “East Jerusalem is not accessible to all Palestinians, so permits had to be obtained from the Israeli military and two participants were denied permits”.
For The Lancet Series on Health the Occupied Palestinian Territory see http://www. thelancet.com/series/health-inthe-occupied-palestinianterritory For the Juzoor Foundation see http://www.juzoor.org/portal/ For UNRWA see http://www. unrwa.org/
The tying of knots was much in vogue at the beginning of May. But few, with the exception of the newly wed British Royal couple, would have devoted more thought to the pastime than the 19 candidates at Augusta Victoria Hospital, East Jerusalem, who attended the ﬁrst basic surgical skills course (BSSC) to be held in the occupied Palestinian territory. Like the Royal wedding, it all went smoothly. All the 19 candidates completed the training—vessel tying and all—to the exacting standards of the Royal College of Surgeons of Edinburgh (RCSE), UK. Unlike the Royal wedding it was done on a shoestring, and involved metres of sheep’s bowels. The RCSE has taught the BSSC in the UK and internationally for about 17 years, but would never have made its way to occupied Palestinian territory had it not been for a family holiday. In December, 2009, Magdalena and Robin Kincaid, two surgeons at the Royal Cornwall Hospital in Truro, took their young family on a trip to Jerusalem. There they hired a car, and set about exploring the West Bank. What they found there would be familiar to readers of The Lancet Series on the occupied Palestinian territory: passionate, dedicated health professionals struggling to provide the best possible care for their patients against a backdrop of failing infrastructure and the paralysis caused by restrictions on the movement of patients and personnel throughout the territory. All they could think about, says Magdalena, was “what can anybody do to make things better?” One of the aspects that came through the conversations with [Palestinians] was “a lack of structure in anything”. This lack of structure is particularly acute when it comes to training.
A pair of candidates practise suturing a vein patch using a school shirt and cow aorta
Course attendees are shown the correct way to handle surgical instruments on day 1
For the Royal College of Paediatrics and Child Health diploma see http://www.rcpch. ac.uk/dpch
Even with permits, Nasser continues, “they did not allow for sleep over in Jerusalem, thus making it another challenge to start each day on time and have students come and go across check points from various regions in the occupied Palestinian territories”. As a result, no candidates from Gaza were able to attend. The course itself was a resounding success, despite there being a far greater mix of ages and levels of experience than in a similar course in the UK. Some of the attendees were already consultants, but were happy to eat “humble pie”, said David Sedgwick, the course convener. For Ronza Salem— one of four female Palestinian surgical trainees—the course was invaluable (“especially the knots”) because it was so closely aligned with the work she does day in, day out. “It gave me more self conﬁdence, because things like end-to-end anastomosis seemed so diﬃcult, but after practicing it, it wasn’t that hard…it’s easy to understand and do it now”, she told The Lancet. Tawﬁq Nasser, Chief Executive Oﬃcer of Augusta Victoria Hospital, was also in no doubt as to the value of the course to his surgical staﬀ. Despite some of his surgeons already practicing in the hospital’s cancer
care centre, Nasser says that “the skills acquired in the course were very practical and added to improving their knowledge in updated new techniques in basic surgical skills. I rarely get such a unanimous opinion from all physicians and surgeons on anything.” For Nasser, it is crucial that his staﬀ are able to train inside the occupied territory. “Sending physicians and surgeons abroad is diﬃcult because of medico-legal regulations that usually prevent our doctors from handson training abroad”, he explains. Equally important is that much of the available training abroad is linked to resources that simply do not exist in the occupied territory. “Hence, hosting experts who can train locally is a real privilege”, he says. In the future, Nasser is looking forward to having team training sessions “in which a full team is trained together (physicians or surgeons with nurses and others) so that we can develop skills uniformly among all clinical practitioners, serving the patient safely and with the highest possible standard of quality care”. But, as valuable as the BSSC was for the surgeons who were able to take part, many will question whether initiatives like this can make a diﬀerence more broadly to the quality of care in the occupied territory. “They will”, says Juzoor’s Nasser, “once they become established and able to be implemented regularly”. Tony Waterston, who has helped the UK Royal College of Paediatrics and Child Health to run its own child health diploma course in the West Bank since 2005, agrees. “The early signs are that [the diploma course] is inﬂuencing practice in relation to communication skills, use of guidelines, emergency care and management of long-term conditions”, he explains. Waterston feels that initiatives like the BSSC, which “directly improve practical skills without increasing brain drain, and generate partnerships which may extend to other areas of learning”, are intrinsically valuable, but making them sustainable will be essential if they are to make a diﬀerence in the
longer term. Crucial to these long-term aims will be reducing the reliance on outside sources of funding, and making the courses as close to self-ﬁnancing as possible. For the child health diploma, Waterston explains, “we are now about to achieve local accreditation, which would mean that the students can be charged for attendance, and this should cover local costs”. Waterston is also hopeful that the increasing adoption of internet video messaging will help to ease some of the access problems caused by the restrictions imposed on movement throughout the occupied territory, especially in Gaza. For Juzoor’s Nasser, the lasting partnerships that schemes like the BSSC help form are crucial for the longterm development of the Palestinian health system. “When teams such as the one form the Royal College of Surgeons cooperate with local Palestinian organisations with a vision to build local capacities, working hand in hand with Palestinian surgeons who are responsible for teaching juniors, or are in charge of surgical residency programmes, they are contributing to the building blocks of a national professional education system in health”, she told The Lancet. One of the most important aspects of the BSSC is its emphasis on techniques that are easy to disseminate more widely; something that Salem is keen to get to grips with. “Already my colleagues are noticing the diﬀerence and are interested in similar training”, she explains. “I’m planning to help them and pass on some of the things that we have learned.” Perhaps as important, says Magdalena, is that an endeavour like this shows that with a “bit of planning, a huge amount of enthusiasm, and not a huge amount of ﬁnancial backing, these courses can be done in Palestine to empower people locally and make them feel they can build on things, and that they have friends abroad and they are not isolated and forgotten”.
David Holmes www.thelancet.com Vol 377 June 18, 2011