More than five billion people across the world do not have access to simple surgical operations. And while this is a staggering statistic, Michael L. Marin, MD, Surgeon-in-Chief of the Mount Sinai Health System, is putting into practice a pragmatic vision on how to provide underserved populations with surgical care. Kyabirwa Surgical Center in Eastern Uganda is an exciting collaboration with local physicians and clinical staff that utilizes state-of-the-art technology in a rural setting—in a way that is both affordable to patients and scalable. The success of this initiative has far-reaching implications—no less than a paradigm shift in global health.
A New Model for Sharing Surgical Knowledge
Kyabirwa Surgical Center focuses on ambulatory surgery—simple procedures in which the patient returns home the same day. “Our approach begins with the recognition that complicated surgery may be out of the reach of some regions,” said Dr. Marin. “If one accepts that as a limitation at the beginning of a project like this, you can concentrate on basic surgeries, which account for the lion’s share of anywhere between 65 or 75 percent of all surgical needs.”
What is revolutionary about the Center is that local surgeons and Mount Sinai surgeons can collaborate in real-time. Using a combination of technologies, including Teams, Zoom, Dynamics 365 Remote Assist, and a HoloLens 2, surgeons like Joseph Okello Damoi, MD, Head Surgeon of the Kyabirwa Surgical Center, can consult with colleagues in New York on cases and even share real-time views from the operating room. For instance, a Mount Sinai surgeon can see exactly what Dr. Joseph (Note: Ugandan physicians are addressed by their first name) sees through his headset, and can make visual notes in mixed reality to offer suggestions during a procedure.
In one collaboration using the HoloLens 2, Peter Taub, MD, a plastic surgeon at Mount Sinai in New York, demonstrated a procedure used to close a surgical site, called a hatchet flap, to Dr. Joseph virtually.
“Sharing surgical knowledge” has a long legacy within the medical profession. Typically, a surgeon who is learning new skills will seek additional training at a medical center or university. Experienced doctors and surgeons may also travel to remote areas on surgical missions. However, both these models are expensive, unsustainable, and only leave a limited impact. Collaboration through technology can bring expertise to the most remote areas, and have a long-lasting ripple effect. For instance, Dr. Joseph may consult with Dr. Taub on a case which is rare in the Kyabirwa region, but may be treated at Mount Sinai on a weekly basis. And as this expertise is shared among colleagues in Kyabirwa, the flow of information and expertise can have an exponential effect on health in the region.
Today, 84 percent of Ugandans live in rural areas—and over 75 percent must travel more than two hours for basic surgical services. Already, Kyabirwa Surgical Center has successfully treated more than 1,000 patients with important surgical problems. And together with their Mount Sinai colleagues, doctors at the Kyabirwa Surgical Center have diagnosed and managed more than 4,000 patients. The location of Kyabirwa was chosen for its proximity to a primary health care facility. In tandem with this facility, Kyabirwa Surgical Center can provide comprehensive medical care to the region’s population.
A Facility Built with Local Hands and World-Class Ingenuity
The Kyabirwa facility and infrastructure were conceptualized with a clean slate. A guiding principle was established to employ local labor and engage the community at every level. The first priority was to bring high-speed internet to Kyabirwa. Working with local technology consultants and government officials and a non-profit organization called the Research and Education Network for Uganda (RENU), seven miles of fiber optic cable were laid between Kyabirwa and the closest city.
The facility itself was designed by a New York architectural firm with an eye to using readily available local materials and manual labor. For instance, over 50,000 bricks and 20,000 tiles were handcrafted from the local clay. The valuable skills and experience gained by local workers will help them gain employment over the long term. And the sourcing of local labor and materials supports the local economy.
Kyabirwa Surgical Center is designed to be self-contained, generating its own electricity and harvesting rainwater. Solar panels not only generate power, but provide essential shade in this land near the equator. Thus, their design mimics the native banana leaves not only in form, but in the function they serve.
The building has three main parts: a reception pavilion and courtyard for patients’ families; an intermediate pavilion that hosts pre- and post-operative activities; and a sterile pavilion with two operating rooms and support spaces. The perforated walls allow for natural ventilation and lighting throughout. Only the operating rooms use air-conditioning.
The innovative design of Kyabirwa Surgical Center has been featured in many architectural journals and has received awards from prestigious architectural associations.
Word Is Spreading About the Low-Cost, Safe Care Provided at Kyabirwa Surgical Center
While the advantages and safety of ambulatory surgery are accepted in many parts of the world, outpatient surgery remains relatively uncommon in much of Africa. Fear about safety and cost are barriers that Kyabirwa Surgical Center has had to overcome. Yet under the direction of Anna Turumanya Kalumuna, Kyabirwa Surgical Center is gaining a reputation throughout eastern Uganda for providing safe, affordable care. Many patients travel up to 12 hours to the Center to receive care. Word has spread relatively quickly about the quality of care that is offered at the Kyabirwa Surgical Center, which charges a nominal fee or no fee at all.
For instance, hernias are a common condition in Uganda. They are so common in this region—the Busoga region—that they have even been named the “Busoga hernia.” However, it’s uncommon to receive treatment because of the personal nature of the condition. Many men simply decide to live with the discomfort, “considering it a private matter, and are not comfortable disclosing the issue,” says Kalumuna.
Her team held a month-long “hernia camp”, where all were able to have hernia surgery at no cost. Now those patients are ambassadors, sharing their experiences and encouraging others to come to the center, she says. In fact, due to the widespread interest, the program was extended for an extra month.
Biopsies, appendectomies, and screenings for cancer—including free breast consultations—are part of the everyday services offered by the Center.
When Miria Namusobya, a 37-year-old mother, experienced severe pain and bleeding during menstruation, she was able to have surgery to relieve her case of endometriosis. “I came with complete faith that they will work on me and I will be fine,” she said. “When I came here, they welcomed me.”
