Dr. Mark Shrime, MD, Ph.D., currently serves as the Mercy Ships Chief Medical Officer. His work with Mercy Ships as well as his extensive medical background gives him a unique insight into the struggles and areas for growth within healthcare systems around the world. He shares his thoughts on the importance of access to surgical care.
Surgery Cannot Be “Optional Guacamole”
“Everybody — from the border of Mali all the way to Dakar — knows my son.”
Daouda’s father is a tall, articulate Senegalese man who lives with his family in a small town on the Malian border. His son, now 14, first noticed a benign tumor on his left upper jaw when he was only 6.
The tumor started small — they all do — but by the time I met him, it had grown large enough to interfere with the way he spoke and how much he could eat.
It’s a benign tumor, but that’s just a technicality. The larger it grows, the more it will interfere with the basic things Daouda has to do to live. Soon enough, it’ll grow large enough to block his breathing.
Daouda’s father knows this. And, of course, he does: he sees his child’s face every day. The boy has grown increasingly isolated and increasingly ostracized. People don’t look him in the eye. They look him in the tumor.
The problem is it isn’t easy to find treatment for his son’s condition where he lives. He’s been trying for eight years.
His first stop was at the health posts near him, but they weren’t equipped to offer the sort of treatment Daouda needed. They sent him to Tambacounda, the Senegalese city nearest him, about 90 miles away. No luck there, either.
Over 300 miles separate Tambacounda from Dakar, Senegal’s capital. The road skirts a couple of national parks as well as the country’s border with The Gambia. It passes by several other health posts and at least one other regional hospital. Daouda’s father knows them all, and they all know Daouda.
It isn’t until he hears of a hospital ship in his country that he begins to feel relief. The night before Daouda’s surgery on board the Africa Mercy, as his father is telling me the story of his eight-year search for surgery, he says he made the 400-mile journey between his home and Dakar half a dozen times, visiting “every single hospital” in the capital city. “And my house is ruined.”
Over the eight years of trying (unsuccessfully) to get care for his son, Daouda’s father spent the equivalent of about $10,000.
Let me digress for a second.
If you’re like me, and you’ve grown up on the American healthcare system, $10,000 doesn’t feel like a huge amount of money to spend on health. Heck, these days, it’ll barely get you an ambulance ride and a Tylenol, it seems.
So, a little back-of-the-envelope math is in order, just to put this sum in perspective. In the second quarter of 2022, the average monthly salary in Senegal sat at about $140. If Daouda’s father was paid the average (and I have no idea if he was), amassing $10,000 would have taken him 70 months (over 5 years) — and that’s if he could devote his entire salary to his son’s care. No other costs. No food, no school fees, no electricity. Just hospital visits for a benign tumor
Also, for more perspective, 70 months of an average American salary is $335,000.
Nearly a decade ago, Dr. Jim Kim, then president of the World Bank, said that surgical care was an “indivisible, indispensable part of healthcare,” a radical position at the time. Surgery was—and still often is—viewed as icing on the health care cake. The sort of luxury our health systems can focus on once they’ve dealt with the pressing needs of nutrition, infectious disease, and maternal and child health.
It’s a view that presupposes that surgery is an add-on, the optional guacamole of health systems. And it’s a view that’s deeply inequitable — a view we can only hold so long as we ourselves aren’t affected by it.
Think about it: if I offered you to move to a country that had successfully eliminated all malnutrition and infectious disease but, in exchange, had minimal access to surgery, would you accept?
I wouldn’t. You probably wouldn’t either. Because we know, implicitly, that we rely on the safety net of an intact surgical system for whenever we get into that car accident, tear that ACL, break that arm, or notice that lump.
And we also know that health is not just physical.
Daouda’s tumor did not just impact his health. It impacted his family’s financial situation. It impacted his ability to go to school, to interact with his community, and to be seen as someone other than his tumor.
A couple of years ago, Dr. Gary Parker said:
There is no good reason why our fellow human beings should be dying of benign surgical diseases.
There are reasons. But no good reasons.
Daouda’s story exemplifies all those reasons. Exemplifies what happens when surgery is viewed as an optional luxury.
But it isn’t because surgery is more than cutting and sewing. It’s more than what happens in the black box that is an operating room. It’s about restoring to Daouda not just the contours of a face unmarked by tumor but the opportunity to re-engage with his rightful seat at the table of humanity.
It’s about releasing his father from the crushing obligation of impoverishing his household in exchange for his son’s care. It’s about giving Daouda’s siblings — and Daouda himself — the chance to go back to school. It’s about correcting the inequity inherent in the disconnect between where the burden of disease is and where the surgeons are.
And we know this. Implicitly. We know that surgery is an indivisible, indispensable part of an equitable healthcare system.
Because when it comes to our own health, we’d never choose to face what Daouda’s father faced. If given the choice, we’d always pick a country with guacamole.
By Dr. Mark Shrime, MD, PhD, Chief Medical Officer