Granting Access

For most families in Somaliland, one of the poorest regions in the world, an accident or condition requiring surgery is more than inconvenient — it’s life-altering and often unavailable. Either they make the great sacrifices required to receive the care they need, or they go untreated. 

Dr. Emily Smith, assistant professor of epidemiology for Baylor’s Robbins College of Health and Human Sciences, estimates that approximately 246,000 children have a surgical need and 75 percent of these needs go untreated, for a variety of access- and poverty-related reasons. 

Her team-based research aims to change that — and is part of a larger multi-country initiative informing the United Nations’ (UN) approach to bridging that gap.

“Children who need surgery often don’t receive that care. We worked in Somaliland to accurately identify the burden of surgical conditions, and examine the barriers to that care, with poverty being the main barrier,” Smith said. “I couldn’t imagine as a mother myself having to make the extremely hard decision to pay for a child’s surgery or feed the rest of the family. That’s the decisions many mothers around the world are having to make.”

Smith co-led the study, published last year in the Journal of the American Medical Association, that uncovered data related to the myriad challenges faced by those needing care. 

In rural Somaliland, the nearest surgeon can be four to 24 hours away. Cost further complicates the ability to receive treatment, including for issues that are debilitating or fatal if not treated. For example, a condition like gastroschisis has a 1 percent mortality rate in the United States but has a 90 to 95 percent mortality rate in low-income countries. This disparity is an issue of access to care and poverty. 

“Our study found that a child with a surgical need in the home is a main predictor of going into poverty and never coming back out,” Smith said. “Eighty percent of people in low-income countries can’t access what they need in terms of surgical care in a timely manner.”

Smith’s research was done in collaboration with the Global Initiative for Children’s Surgery (GICS), along with researchers from the Duke Global Health Initiative, where she served as a research scholar and remains an adjunct assistant professor of global health. GICS is a non-governmental organization comprised of doctors and medical professionals from over 100 countries to help children worldwide access surgical care. She is one of the only non-surgeons or health providers within GICS.

Implementation, through targeted intervention, is the next step.

“We know how many pediatric surgeons we need, and we know the hotspots in the country that need a new hospital, referral system or ambulance,” she said. “We want to find the money to be able to implement that, through grants or donors.

Real data has the potential to empower individuals and impact the quality of life in Somaliland and other nations. GICS’s work caught the attention of the UN, and Smith was chosen to present at last year’s General Assembly about future international efforts to increase access to surgery.

“Some of our work has shown surgical care is actually as cost-effective as a bed net for malaria or immunizations for children, both public health programs already going on in low-income countries,” Smith said. “For instance, an untreated club foot prevents a student from walking to school, thus perpetuating the cycle of poverty. A cleft lip or palate impairs eating. Maybe they can go to school, but they’re not receiving proper nourishment, thus resulting in malnutrition and stunting. We need to think seriously about what disability and how, untreated, it can increase the cycle of poverty.”

Health is one of the signature initiatives of Illuminate, Baylor’s strategic plan and offers many opportunities for interdisciplinary research and partnerships across campus and to make a true difference to improve lives.

“We hope to do more advocacy with data as our foot-in-the-door. You can say that babies are dying around the world and everyone agrees, but when you have data to support that, you can’t throw it away,” Smith said. “Ministries of Health, the UN, and WHO listen to data.”