Dr Catherine Mohr
Intuitive Surgical, maker of the daVinci surgical robot
Dr Duthie raises many excellent points in his blog post, Limited Resources. This is an essential conversation that we, in the global medical community, must continue to have. I would hesitate to assert though, that clinicians or companies from economically developed countries are in the best position to determine what appropriate technologies are needed for the developing world.
Throughout my career, I have always been focused on the development of appropriate technology for solving real world problems. Technological leaps have again and again been used to increase large systemic efficiency and reduce individual suffering. Robotic surgery may seem a rather ‘boutique’ way of tackling this larger global healthcare problem, but I believe that the technological advancements being made in initially limited markets today have far reaching implications, and the potential to move us forward globally. The key is to understand when we are applying technology appropriately, and to accurately assess where technologies are in their longer-term arc of development.
Early on in my surgical training, I had one of the most eye-opening, profoundly world-view-adjusting conversations it has ever been my good fortune to have. This conversation was with a brilliant minimally invasive surgeon from India who was spending his career traveling from hospital to hospital with a suitcase full of laparoscopic surgical instruments soaking in glutaraldehyde.
At each hospital he visited, he would ‘set up shop’, and perform a continuous string of minimally invasive surgeries (MIS) until he had exhausted the backlog of patients who had been ‘saved up’ for him. He re-sterilised his own instruments, and travelled with all the equipment he needed. This was only possible because he had managed to pare down his requirements to the absolute minimum set of technology to safely perform MIS. The hospital provided a surgical table, sterile supplies such as drapes and gloves, a room, and the anaesthesia. He brought everything else with him, and the patient paid the same price they would for an open surgery.
Until that conversation, I, like many others, had viewed MIS as a luxury. MIS provides improved post-operative pain, faster return to work, and better cosmesis, all of which are wonderful things, if you can afford them. It is the patient who reaps the greatest benefit, however, and in a world of scarce resources, these benefits may seem to be a bit of a frivolous luxury.
Even in the developed world, insurance companies and public healthcare systems will only pay for the increased cost of laparoscopic and robotic surgeries if they offset ‘real’ costs such as complications, length of stay, and long-term support. Fortunately for patients, when MIS technologies are applied appropriately, these savings do offset the cost of laparoscopic and robotic surgeries, and as a result, MIS is inexorably replacing open surgery throughout the developed world.
But why does this surgeon view MIS as a moral imperative in developing countries? Why India? Why does he feel it is even more important in developing countries than in the western world? Primarily, this has to do with the disproportionate economic impact of extended disability in a world without a safety net. His patients are often the sole economic engine of their family. When they need surgery, the entire extended family uproots itself to come with the patient to the hospital, and stays the duration of convalescence to provide food and the post-operative care, which the hospital does not. Until the patient is out of the hospital, the family is displaced and there is no money coming in, which is often economically devastating for the family. This reality was the foundation of his conviction that everyone in the world deserves MIS. He made me a believer and helped me to understand that the developed world is not in a position to determine appropriate technology for his world.
How significant a difference does MIS make in this scenario? The time in the hospital is usually a few days shorter for MIS when compared to open surgery, and this is a primary driver of savings in developed countries. In developing countries, the economic impact of the difference in convalescence overshadows acute hospitalisation.
These differences in convalescence time have been studied well in Sweden.1 With MIS, the patient was back to work 11 days after surgery, and with open surgery, it was on average 49 days. In a world with paid time off, this is a subject for economic optimisation. In a world without any social safety net, this is a crucial difference.
Understanding the implications of this is challenging. It requires us to look at these problems in a different way. We must examine not just how much technologies cost, but what are the real (and sometimes unexpected) costs of not using a technology? How can we do what that brilliant Indian surgeon did, and pare down our ‘tool kit’ to the minimum necessary, and appropriate technology? There are no easy answers.
The history of medical philanthropy is riddled with well-meaning acquisitions and donations of expensive pieces of medical equipment to disadvantaged areas. This equipment is designed to function within the medical ecosystem of the Western world where resources such as advanced training, capital, and a reliable supply chain are readily available. Distressingly often, the result of someone trying to do something good in the developing world goes to waste due to a lack of training, or the cost of supplies.
So what is a techno-utopian to do? I believe that it is to keep pushing the technological envelope. I take comfort in the historical progression of technology from boutique early adoption to ubiquity. In the 30 years since the first modern cell phones, cell phone technology has gone from being confined to the very rich to an essential form of communication with 83% penetration in developing and emerging economies.2
Emerging economies do not need to follow the technological sequence that more developed economies followed. In many cases, developing countries have gained modern capabilities while bypassing large infrastructure investments, such as the ubiquitous landline phone deployment that took decades to roll out and cost billions. Success occurs when educated members of communities decide on priorities, and what the appropriate technologies are to meet their needs.
Everyone deserves MIS. I believe that robotics will be a major part of making MIS accessible to all. Our challenge is to evolve this early technology into a globally appropriate technology. History is on our side.
1. Hohwu et al. Open retropubic prostatectomy versus robot-assisted laparoscopic prostatectomy: a comparison of length of sick leave. Scand J Urol Nephrol. 2009;43(4):259-64.
2. Pew Research Center Spring 2013 Global Attitudes survey. 2013.