— Children in Somaliland suffer a
significant burden of health conditions — particularly congenital
deformities and wound-related conditions — that could be bettered by
surgery, but most of these needs are going unmet, according to a study
co-led by Baylor University and Duke University and published in the Journal of the American Medical Association.
The need is especially pronounced in rural areas of Somaliland, a
country in the Horn of Africa with a population of more than 3.5 million
residents, most of whom live more than two hours from a surgeon and as
far away as 24 hours. The problem is magnified by the fact that the
country is predominantly low-income, said lead researcher Emily R.
Smith, Ph.D., assistant professor of epidemiology in Baylor’s Robbins College of Health and Human Sciences and adjunct assistant professor of global health at the Duke University Global Health Institute.
“With one of the highest infant mortality rates in the world in
Somaliland, it is essential to accurately identify the burden of
surgical conditions in the population, particularly among the vulnerable
population of children,” Smith said. “As a mother myself, my work is
very motivating. A mother’s love for her child, particularly when that
child is sick, is the same regardless of what part of the world you live
in. Thus, the ability to ‘echo and amplify’ other mother’s voices
through this study is a strong advocacy tool. I feel very fortunate to
play a part in this voice, as a mother, researcher, and friend with my
Somaliland colleagues.”
The investigation — “Prevalence of Pediatric Surgical Conditions Across Somaliland”
— was done in collaboration with the Global Initiative for Children’s
Surgery, a network of children’s surgical and anesthesia providers from
low-, middle- and high-income countries, with additional researchers
from Duke University’s Duke Global Health Institute.
The findings highlight the need for expanding access to surgery for
children in need, as well as screening and prevention programs, Smith
said.
Recent estimates are that some 5 billion people, predominantly in low-
and middle-income countries, lack access to safe and affordable surgery.
Surgical conditions contribute to nearly a third of the global disease
burden, but little priority has been given to addressing gaps in
surgical care for children, researchers noted.
Mortality rates of infants and children younger than 5 in Somaliland are
more than twice as high as overall mortality rates in sub-Saharan
Africa, and Somaliland is classified as the fourth poorest country in
the world by the World Bank. Although Somaliland is not recognized by
the United Nations as a separate country, Somaliland declared itself
independent after the overthrow of a dictator in 1991 and remains an
autonomous region of Somalia.
For the study, a team of Somali data collectors, led by a Duke graduate
student, collected data from 871 households throughout the country using
the Surgeons OverSeas Assessment of Surgical Needs survey. Participants
were 1,503 children aged from infancy to 15 years. The survey included a
section on household demographics, deaths and poverty, as well as a
section about children’s history of surgical conditions.
Parents or guardians were asked whether two randomly selected children
from the household had ever had a wound, burn, mass/goiter, deformity or
specific problem with a body region. If so, conditions were confirmed
as surgical by a pediatric surgeon. Respondents also were asked if any
kind of care was provided at a health care facility by a doctor or
nurse, or if any care was provided by a traditional healer outside of a
health care facility.
Researchers found 221 surgical conditions identified among 196 children,
with only 53 of those having been corrected surgically at the time of
the survey. The most common conditions were congenital anomalies (33.8
percent) and wound-related injuries (24.6 percent).
Most families in the survey did not seek health care or reported seeking
health care but not receiving surgery due to lack of access to health
care or lack of enough money to pay for the surgery.
Of the approximately 2 million children in Somaliland, an estimated more
than 250,000 children have surgical conditions, with 40 to 75 percent
of those unable to access surgery or appropriate treatment, Smith said.
One of the study’s limitations is that researchers were unable to assess
the severity of a condition. For example, a child may come in with a
congenital condition, such as clubfoot, that is not highly fatal but is
disabling. In contrast, a child may come in with a congenital condition
that is highly fatal, such as gastroschisis, a birth defect in which the
intestines or other organs are found outside the baby’s body but
attached to it. Further research is needed to delve further into this
problem, Smith said.
Researchers are using this study to assess where the greatest needs are
in the country and develop targeted intervention plans to meet those
needs. Work also is ongoing to reduce the financial burden of surgery
for children in the country.
“The partnership between my Somaliland colleagues and researchers here
at Baylor and Duke highlights the great work that can be done to impact
people around the world when we collaborate together,” Smith said. “We,
the pediatric surgeons and health care workers in Somaliland, the
Ministry of Health in Somaliland, the researchers here in the US, all
play a role in advocating for the poorest of the poor.”
All researchers are members of the Global Initiative for Children’s
Surgery. Co-researchers included Tessa Concepcion and Henry E. Rice,
M.D., of Duke University’s Duke Global Health Institute; Mubarak
Mohamed, Shugri Dahir, M.D., and Edna Adan Ismail of Edna Adan
University Hospital in Hargeisa, Somaliland, Ph.D.; and Dan Poenaru,
M.D., of the department of pediatric surgery at McGill University Health
Centre, Montreal Children’s Hospital, Montreal, Quebec, Canada.
Funding for the study was provided by Duke University’s Duke Global
Health Institute and grants from Baylor’s Robbins College of Health and
Human Sciences.
ABOUT EMILY SMITH
Emily Smith, Ph.D., assistant professor of epidemiology at the Robbins
College of Health and Human Sciences at Baylor University, also is an
adjunct assistant professor at Duke Global Health Institute at Duke
University. Her research interests include global surgery and
strengthening of health systems in low-income countries. Her research
takes place in Uganda, Nigeria, Somaliland and Latin America.
ABOUT BAYLOR UNIVERSITY
Baylor University is a private Christian University and a nationally
ranked research institution. The University provides a vibrant campus
community for more than 17,000 students by blending interdisciplinary
research with an international reputation for educational excellence and
a faculty commitment to teaching and scholarship. Chartered in 1845 by
the Republic of Texas through the efforts of Baptist pioneers, Baylor is
the oldest continually operating University in Texas. Located in Waco,
Baylor welcomes students from all 50 states and more than 80 countries
to study a broad range of degrees among its 12 nationally recognized
academic divisions.
ABOUT ROBBINS COLLEGE OF HEALTH AND HUMAN SCIENCES AT BAYLOR UNIVERSITY
The Robbins College of Health and Human Sciences at Baylor University
was established in 2014, a result of identified priorities for
strengthening the health sciences through Baylor’s strategic vision, Pro
Futuris, and the University’s Illuminate academic strategic plan. The
anchor academic units that form Robbins College – Communication Sciences
and Disorders; Family and Consumer Sciences; Health, Human Performance
and Recreation; Public Health; and Division of Health Professions –
share a common purpose: improving health and the quality of life. The
College promotes a team-based approach to transformational education and
research that has established interdisciplinary research collaborations
to advance solutions for improving quality of life for individuals,
families and communities.
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