Trauma-related mortality decreases after the institution of a general surgery residency program in sub-Saharan Africa: The Malawi experience

BACKGROUND: Many factors contribute to the burden of surgical diseases, such as trauma, in sub-Saharan Africa, including a paucity of international funding, a shortage of trained clinicians, and underdeveloped infrastructure. Training surgical providers is one solution that has been proposed to reduce the mortality and morbidity due to these diseases in the region. Kamuzu Central Hospital in Lilongwe, Malawi, in partnership with the University of North Carolina at Chapel Hill, established a general surgery residency program in 2009. The purpose of this study is to evaluate changes in trauma-related mortality following the institution of this residency program. METHODS: We review data related to the burden of noncommunicable and surgical disease in sub-Saharan Africa, as well as access to surgical providers and the shortage of healthcare workers in the region. We perform a literature review of proposals aimed at improving the access to surgical services in sub-Saharan Africa. We then present Malawi-specific data, including economic and health indicators, healthcare structure, access to surgical providers, and trauma-related burden of disease. Finally, to determine the influence of the general surgery residency on trauma related mortality at Kamuzu Central Hospital, we perform a retrospective analysis of patients in the hospital's trauma surveillance database, from 2009 to 2014. A logistic regression model was constructed to compare the odds ratio of in-hospital death. RESULTS: In 2009 there were 3 general surgery residents at KCH; this number increased to eleven residents in 2014. During the period of study, 82,534 patients were recorded into the trauma registry database at KCH; the majority were male (72.1%), and mean age was 23.1 years (SD: 15.7). Trauma volume increased for each of the years under study, with 8725 patients recorded in 2009 and 15,998 patients in 2014. Odds of in-hospital death decreased every year as compared to the referent year, when adjusted for primary injury type (severity); age; and gender. CONCLUSION: While surgical burden of disease in sub-Saharan Africa is a complicated issue, training general surgeons in a resource-poor setting represents an effective intervention to help reduce trauma mortality in the region.Master of Public Healt