January 29, 2014 | 1
When Italy’s populist Five Star Movement held an online poll last year to probe who might make the best presidential candidate, surgeon Gino Strada came in second. Laughingly, Strada declined any possible entreaty to run with an Italian variation of “I will not accept if nominated and will not serve if elected.” Strada’s star, nonetheless, continues to rise in the NGO world. “Open Heart,” a film about the nearly seven-year-old center for heart surgery on the outskirts of the Sudanese capital of Khartoum was nominated for an academy award for best documentary last year, and a petition is apparently circulating for Strada to get the Nobel Peace Prize.
From his home base in the Sudan, Strada, 65, is less worried about a legacy than in expanding the scope of Emergency, the organization he founded in 1994 to treat civilian victims of war. Instead of focusing on casualties of global conflict, the group now has plans to build on the success of the Salam Centre for Cardiac Surgery to establish new centers in different African countries, each of which will provide free-of-charge care in a particular medical specialty ranging from cancer to obstetric surgery. The Salam center is trying to address the medical needs of the immense population of African children whose hearts have been damaged by rheumatic fever because of a lack of access to antibiotics.
Emergency, which receives 30 million euros annually from donors and national governments, has 55 facilities worldwide: 37 in Afghanistan, three in Sudan, two in Sierra Leone, another in the Central African Republic and yet another in Iraq. It also has 11 in Italy, set up initially to serve the country’s growing immigrant population.
Strada is a previous author for Scientific American and the subject of a 2002 profile. I phoned him recently in Khartoum to talk about Emergency’s new direction and its unwavering efforts to provide medical care in Africa or war-torn countries at a level that compares favorably to treatment a patient might receive in Milan or Boston.
Can you tell us about your approach to establishing new hospitals in Africa that places emphasis on building state-of-the-art facilities?
If I look at the health indicators in Africa, I see something that is very, very similar to what the situation was in Europe 200 years ago. In other words. medicine has not developed. Millions of people are suffering and dying and so we have to ask how do we reverse this trend? Should we continue with the traditional approach of providing the most simple things and stop there or is it possible to really advance medicine?
Look at what happened in Europe 100 years or 200 years ago. When we started, it tended to be a mix of magic and supernatural and trial-and-error practices and there was an attempt to try to make it into a science. To do that, we established universities. We did not establish feeding centers in refugee camps. We established places of knowledge and places of scientific development.
So how do you do things differently in Africa?
If you go to the majority of health facilities in Africa, the facilities are completely filthy. There’s no hygiene whatsoever. The staff doesn’t go to work, patients are attended by family members. Nothing’s free of charge, nothing is available. What do you expect, do you expect things to develop one day to become the Boston Children’s Hospital?
If you start with a completely different approach to building medicine from top to bottom by establishing high-standard facilities, there is a possibility you can start training qualified personnel and helping other centers not at the same level. For example, simple pediatric outpatient clinics could function for young patients for early diagnosis of rheumatic fever rather than waiting for these patients to come nearly dead to a center of cardiac surgery
If you have these kinds of facilities that represents a model that can be replicated that proves that outstanding results can be achieved even in difficult or impossible situations, If you do that you open possibilities. I’m not saying you solve the problem, but you create a chance for the problem to be solved.
Do you think that your center has started to influence the way medicine is practiced in Africa?
It’s difficult to establish a precise relationship in terms of cause and effect. If I look at the situation and how it’s evolved both in Sudan and other African nations, this center remains the only one free of charge for cardiac surgery. We have patients from 25 countries outside of Sudan.
In many of these countries, we have established contacts with national doctors for initial screening and later for followup. We’ve also discussed that health care should be available as a basic human right and have convinced governments to try an experiment to furnish free of charge surgical care.
Over the last seven years or so, there has been some changes in health policy in Sudan. Before you had to pay. It wasn’t much, just one or two pounds, but you had to pay like going to movies to enter a hospital for visiting friends or relatives. Four or five years ago, pediatric health care became free of charge. Then they decided obstetrical services should become free of charge. So we see a slow movement in that direction. And many hospitals have improved their level of hygiene. It’s a long process that took hundreds of years in Europe.
Much medical care throughout the world isn’t free…
Unfortunately there’s been a reverse tendency in the last 30 or 40 years that medicine is only a business like selling cars. There are people who sell medications or medical care in the same way. It’s not exactly a great idea. You see that in Europe now. More and more people can’t afford care. Italy is a place of immigration. Initially our centers there were targeting immigrants. And then slowly we realized that 20 to 25 percent of the patients are Italians who can’t afford to pay for the national service.
So how do you get funding?
It’s not just a problem that concerns Emergency or Emergency in Sudan. It’s an overall problem that involves all societies in European countries. We call health expenditures what in the mind of most people equal what the government spends for our health care. In Italy, the annual budget for health is about 100 billion per year.
Thirty percent of that goes into the pockets of investors through arrangements between private institutions and the public system and reimbursements and so on. So let’s start to eliminate that quota of the cost of health and then the cost starts to look much more reasonable
If a government is not concerned with the health of its people, do we need governments? And I think that question was posed probably for one of the first times in the Declaration of Independence in the United States, no? Government is established to protect life and liberty. If you don’t provide health care to people, how are you protecting their life?
Without a relationship with the private sector, would you be able to maintain the same level of high quality care, either in Italy or in the center in Sudan?
We are able to maintain high standards of care. We don’t have profits in our organization. No one gets money apart from salaries, which basically are due to people because everyone has to eat and have a decent standard of life. If someone told us years ago that we’re getting the kind of clinical results that we’re now getting at the Salam Center, I would have been quite skeptical.
What have been your results?
If I look at the operative mortality in the United States or Canada for cardiac surgery for the replacement of a mitral valve—we only do cardiac surgery at the Salam Center—the mortality, according to the Society for Thoracic Surgeons, has been six percent during the past 12 years. Here at the Salam Center, we have 1.2 percent. The first comment everybody makes is that we operate on younger people. That’s true, but younger doesn’t necessarily mean healthier. Who is more healthy, a 70-year old man who needs mitral valve replacement and was playing tennis until weeks before or a 13-year old patient weighing 12 kilos with severe malnutrition. If we have four or five times less mortality than that recorded across Europe or the U.S., there must be a reason.
Why are the results so good?
I’m convinced that the first reason for the good results is that we’re very, very strict about hygiene. Another reason is the commitment of the people who work for us and that our patients are not customers. It’s also clear that a center doing 1,000 cases of valve surgery a year gathers more experience than a center doing just surgery once in a while.
What about the costs for a surgery?
The key point is that’s it’s possible to have high-quality centers in Africa with reasonable costs. If I calculate the cost of open-heart surgery here with a valve replacement, the cost of an operation is in the range of 3,000 euros. The question is why in hospitals in Italy, the cost is 20,000 euros. Where does the rest of the money go? And that takes us back to the previous conversation, if health becomes a business, if a patient is a client, that’s the end of medicine.
Would there be more of a public-health benefit if you spent this money on vaccines and antibiotics instead of on more sophisticated care?
If you’re comparing the cost of treatment of s patient with heart disease with treatment of a patient with malaria, tuberculosis or hepatitis, the cost of cardio treatment is much higher for sure. But again this way of thinking makes sense if we’ve established first, and we did not, that the main factor determining what we do for health is money.
If you look at human rights, the situation changes completely. Imagine that you tell someone in a hospital in Boston or Washington that if you have an ulcer or gastritis, that’s not a problem for treatment, but if you’ve got cancer and you need chemotherapy the treatment is expensive and there’s no way it can be provided. If that happened in the U.S., people would start shooting in the streets. Why in Africa does the right to medical care have to be confined to stupid and preventable diseases that should be dealt with, but other diseases that are part of the normal human right to healthcare are excluded? The problem is not to put one against the other, malaria vs. rheumatic fever or tuberculosis versus congenital heart disease. The problem is to understand we have to solve both problems.
So what about the epidemiology for rheumatic fever in Africa?
Rheumatic fever is becoming the leading cause of death in Africa and cardiovascular disease, according to WHO, will become the leading cause of death in very few years in Africa. The link to poverty is very clear. The WHO estimates that there are 20 million people with rheumatic fever in Africa. They require two million hospitalizations each year. There are five million people in need of heart surgery because of that. There are 300,000 deaths every year, two thirds of these deaths are children and children below the age of 13. The magnitude of this tragedy looks a bit different in that light. So we can ask why we’re not looking at typhoid. I don’t know if typhoid is worse than rheumatic fever and, in the end, I don’t care. These two need to be satisfied together and everyone has to do something. We do our own small thing and do what we can do. There are immense problems to deal with primary care in Africa;
You’ve got centers all over the world, what comes next for Emergency?
We have a program to build 10 centers of excellence in Africa in different disciplines, all in different countries, going from pediatric surgery to obstetrics and gynecology. There’s not one hospital in Africa where you can have proper treatment and free of charge for cancer. We’re also going to look into physical rehabilitation, to build prostheses, There’s a lot of handicapped people because of the wars. The only thing we’re not missing is the patients.
How will you get started with the centers of excellence?
We’re hoping to construct a center in Uganda. It will not deal with cardiac surgery. It will be a center of excellence in pediatric surgery, all surgery apart from traumatology. In most cases, it will be to correct congenital defects, for instance, urinary malformations. It will also be a center that is free of charge and it won’t matter where the patients come from. Uganda will pay 20 percent of the overall cost of the program and there will be free of charge visas for everyone who wants to come to be operated there. If we get the resources, we will start in a very few months. The hospital has already been designed by one of the greatest architects in the world, Renzo Piano, who is a friend of Emergency.
You have been mentioned in Italy as a possible candidate for president?
There are other people who are much better than me in that role. I like the appreciation shown for our work and the fact we are honest and transparent in what we do, which in Italy is quite rare. Apart from that, I’ve never been impressed with taking an active part in politics; As a joke, I say that I would like to be Minister of Health for one day.
What would you do?
I would be the minister of public health not of private health. In Italy you have a lot of private hospitals. The first thing you do when you finish building this hospital and it’s still smelling of paint, you establish an agreement to get funding with the national health system. I would ensure that those who work in public hospitals work in public hospitals. For those who work in private hospitals, the government will not pay for that treatment because we have outstanding public hospitals. This is a dangerous mix. This is what creates difficulties in the national system, the drainage of resources toward the private sector.
The American political scientist Edward Luttwak said that you would cut a ridiculous figure as a presidential candidate because you have said that you’d be willing to give medical help to the Taliban, which has previously attacked one of your facilities in Afghanistan, and doing that would be the equivalent of giving help to the Nazis in 1944 I’m curious about your reaction to his statement.
My reaction to this type of comment; is very simple. In my opinion, human rights have to be for everybody otherwise there’s no point in calling them human rights because they privilege only one sector of humanity. Among these human rights, there is also the right to be stupid. People who have this kind of argument are simply impotent. I’m a doctor, a surgeon. If I get a person who comes in with a gunshot wound or a heart attack, what shall I do—ask for whom you vote, what’s your political opinion, what’s your religion what’s your ideology? In my opinion, human rights are for everybody. I have no enemies. My duty is to provide the best care I can to those in need without any stipulation or discrimination.
Image sources: Emergency