Why A Surgeon Taught A Non-Doctor To Do Brain Surgery

Enlarge this image toggle caption Tony Bartelme Tony Bartelme

Enlarge this image toggle caption Liesbeth Hoek Liesbeth Hoek

Dr. Dilantha Ellegala, a brain surgeon, trained someone who isn't a doctor to do brain surgery.

That is the story featured in the new book A Surgeon in the Village by journalist Tony Bartelme.

This unlikely turn of events had its origins in 2006, when Ellegala was volunteering for a short stint at Haydom Hospital in northern Tanzania. When he became aware of the nation's dire doctor shortage, he came up with a plan: He'd offer a Tanzanian a one-on-one crash course in neurosurgery — how to diagnose a tumor, drill through a skull and perform some basic techniques — no medical school degree required.

Ellegala didn't go to Tanzania to teach. The Sri Lankan-American had just wrapped up a demanding fellowship at Harvard's Brigham and Women's Hospital, and needed a break from his stressful American career. He had to hunt pretty hard to find a place in Africa interested in his skills and prestigious background. Several NGOs turned him down.

"People laughed and said, 'We don't need neurosurgeons.' At the time, it was all focused on infectious disease," Ellegala explains. "When you looked on the television and at the news, that's all anyone was talking about in Africa."

When Ellegala arrived at Haydom, which had been established by Norwegian missionaries in the 1950s, he witnessed just how poor conditions were. A long drought had left many people severely malnourished. "There were rooms with children with tuberculosis, rooms with children with burns," he says. "There were two or three patients to a bed."

The only doctors around were visitors from abroad, like Ellegala. Locals were mostly clinical officers; their education was, as Bartleme explains, "roughly equivalent to an American paramedic or nurse practitioner, minus a college degree." This created a divide that made Ellegala uncomfortable — and angry.

"At meetings, all the Westerners were sitting in chairs in the front, while Tanzanians were standing in the back," he says. "I saw this pattern. We come in to do the work and then we leave. Local personnel is put in the background. As doctors, we learn we can help somebody, so we do. But I could see the unintended consequences of that."

It had created a mindset of dependency. The Tanzanian staff could not help. The outsiders could.

Through a donation, the hospital had just acquired a CT scanner. "They had CT scans of tumors and hydrocephalus, and nobody knew what to do about it," Ellegala says. Of course, he knew. The tumors could be removed, and the patients with hydrocephalus — a buildup of excess cerebrospinal fluid — needed shunts inserted.

But Ellegala couldn't fix all of these problems on his own. "I knew I could work dusk to dawn every day and not make a dent. I'm only there for six months. There has to be a way to make it better," Ellegala says. That's when he had his big idea: "We had to teach our local partners."

Instead of tackling the caseload himself, he decided to enlist a Tanzanian. He'd spotted Emmanuel Mayegga, who was an assistant medical officer, which meant he'd had a bit more training than most of his colleagues at Haydom. Plus, he had the swagger and demeanor of a surgeon.

"If there hadn't been anybody like that, I wouldn't have done it," Ellegala says, although he never doubted the validity of his mission. He could save a few dozen patients during his time in Tanzania, but when he left the hospital, so would any hope of treatment: "I knew it would be controversial, but not to anyone in Tanzania. The locals said, 'Yes, please do it. Otherwise, they're going to die.'"

With the approval of the top Tanzanian supervisor at Haydom, Ellegala got to work.

Two weeks in, Mayegga touched the tip of his moistened surgical glove to a patient's brain for the first time. A month later, he was performing surgeries. By three months, he was able to do them alone in the room. "In six months, he could do all basic cranial neurosurgery, remove tumors near the surface, put in shunts. He even started to teach a U.S. medical student," Ellegala says.

As remarkable as that sounds, it's not much of a surprise to Adam Kushner, an associate in the International Health department at the Johns Hopkins Bloomberg School of Public Health. He's the founding director of Surgeons OverSeas, which focuses on bringing up the level of surgical care in developing countries. Although Kushner has never crossed paths with Ellegala, he's seen similar tactics employed with success.

While working as a general surgeon in Malawi in the early 2000s, Kushner knew a clinical officer who'd been trained to treat hydrocephalus. Even with all of Kushner's American education, that's something he had never learned to do. And through a program in Ethiopia, Kushner has helped train clinical officers in essential surgeries, including C-sections and appendectomies.

"There's an expectation that for certain functions you need certain people with certain training," Kushner says. "And that's not wrong." What happens, he says, if there's a complication and the person doing surgery doesn't have training beyond this specific procedure?

But there's also reality to contend with. People need surgery to survive, and there isn't always a surgeon around.

Kushner highlighted the issue last month at the Global Surgery Conference at Montreal General Hospital. He presented his research indicating that there are 288 million people who need surgery right now — but don't have access to it — in 48 countries identified as low-resource, meaning they have a per capita health expenditure of $100 or less annually. There simply aren't enough surgeons around to do that much work.

Kushner has personally experienced the effects of this shortage: During part of his time in Malawi, he was the only surgeon for a population of about five million. And it's not just a problem abroad, he adds, noting that getting timely surgery can be a challenge even in remote parts of the U.S.

But training non-surgeons — and non-doctors — only makes sense, Kushner cautions, if it's what the local population wants.

That's what happened at Haydom, says Ellegala, whose philosophy was to let Mayegga do the talking and explain the situation to patients. Ellegala's job was just to serve as a guide. "To do this, you have to put your hands behind your back and take two steps back," he says.

For Ellegala, that was not such an easy thing to do, especially because he knew life-threatening mistakes could be made. Ellegala had years of training. Mayegga was a quick study but still a novice. But, he adds, it was the only way to prepare Mayegga for his impending departure.

Indeed, Ellegala went back to the States and a new job as director of neurotrauma at Oregon Health and Science University in Portland, Oregon. But he couldn't stop thinking about Mayegga, and how this model could be replicated.

"My goal at that time wasn't to create neurosurgical care in Tanzania," Ellegala says. "It was to show they could train their own. Neurosurgery has a certain aura to it. This was to prove a point: If you can do this in one of the most remote hospitals in the world, in one of the most advanced specialties in medicine, you can do it anywhere."

He landed a grant to study how Mayegga's patients were faring. And soon, he was back in Tanzania.

The review showed that Mayegga's results were promising — many patients he treated solo were staying alive. But news of this experiment had gotten out, and not everyone was pleased about it, including Kenyan neurosurgeon Moody Qureshi, who was developing a curriculum to teach neurosurgery in East Africa. Kenya's medical education system was much different than Tanzania's, Ellegala explains, so teaching a non-MD was unthinkable in that country. Qureshi was even considering suing to put a stop to the program.

To defuse the situation, Ellegala invited Qureshi — as well as one of Tanzania's three neurosurgeons — to Haydom. Upon seeing Mayegga in action and the need for care firsthand, plus getting reassurance from Ellegala that he wouldn't be training any Kenyans without a medical degree, they all agreed to collaborate in the future.

So Haydom's unconventional brain surgery training continued. Ellegala dove into teaching Mayegga more advanced techniques, and Mayegga began doing some instruction of his own. His first student was Emanuel Nuwas, a local Tanzanian who had just completed medical school. (And with Nuwas doing brain surgery at Haydom, Mayegga was eventually able to leave to attend medical school. Now, he's both a doctor and a brain surgeon.)

Flash forward to today and Ellegala's NGO, Madaktari Africa, is using the "train forward" model to bring foreign medical personnel to Africa to teach rather than practice and introduce more skills to all kinds of health workers, including cleaning staff and data analysts. The current focus, according to director Maarten Hoek, is on cardiology at Jakaya Kikwete Cardiac Institute in Dar es Salaam.

But when they're introducing brain surgery, Ellegala notes, the process is much the same one he used with Mayegga. They begin by examining CT scans. "The first thing is I talk about what we're looking at," says Ellegala, who points out the anatomy visible in the image. After studying a scan, then come the questions: "Is this one normal or abnormal? If it's abnormal, is it emergent?" (Meaning it's an emergency that requires immediate action.)

"We make it very simple. It's very gentle teaching," Ellegala says. "If they get it wrong, I say, 'That could be.' I don't want to make somebody feel bad like in Western culture in medicine. If I said something wrong in my residency, I'd be screamed at. If you go in with that mindset, you lose them."

Another critical step, he says, is giving them access to patients. "Just looking at pictures didn't work at all. It has to be hands on," Ellegala adds.

When it comes to instructors, Madaktari Africa has tested several different models. They've tried sending neurosurgeons for just a few weeks at a time, but lining their visits up back-to-back for continuous training. That doesn't work as well as one surgeon coming for six months or more, Ellegala says. "It's not just somebody coming in and telling you what to do," he explains. An effective teacher becomes a part of the community and learns the nuances of the culture.

As for Nuwas, the man trained by Mayegga? He's now the first-ever Tanzanian medical director at Haydom. (Norwegian doctors had always filled the role before.) That's a big shift, says Ellegala, whose current practice near Lynchburg, Virginia, is helping fund Madaktari Africa.

Last year, when Ellegala took his most recent trip to Tanzania, he felt that the place had transformed. "There's a sense of pride and joy that wasn't there before," he says. "If I had to say what is it that I feel best about, it's not training someone in neurosurgery. It's that someone is doing what they thought couldn't be done. A local village boy [Nuwas] who became a doctor can be the head of the hospital."

Vicky Hallett is a freelance writer in Florence, Italy. She was previously a reporter and fitness columnist for The Washington Post.