Arbutus Medical’s DrillCover technology is now being employed by SALFA – the Malagasy Lutheran Health Department – in Madagascar, to treat long bone fractures. The DrillCover PRO is being adopted in a program to train the newer generation of surgeons in the country to deal with trauma cases.
SALFA has expanded greatly over the past decade and is one of the largest Lutheran healthcare systems in the world. It now includes 10 hospitals, over 40 rural clinics, one of the country’s top nursing schools and medical support for spiritual healing centres across the country.
Madagascar has only a handful of orthopedic surgeons to serve its population of 25 million – most in the capital city of Antananarivo – leaving millions without access to safe surgery. There are several capacity building programs for surgeons in Madagascar and Dr. Volker Roth, an orthopaedic and trauma surgeon from Germany, was part of one such program.
In January 2023, Dr. Roth and his colleagues spent three weeks in Antsirabe and prepared lectures which covered topics of general and trauma surgery, hand surgery and X-ray interpretation. There was a workshop where participants worked on plastic bones, and training sessions where they were taught suture techniques using bowels and tendons from cattle.
The Malagasy Lutheran Health department is now facing generational change as their few experienced surgeons are close to retirement. “The idea was to train the new generation of doctors doing surgery”, said Dr. Roth. “There are not many opportunities for continuous medical education in Madagascar. So the plan was to offer a workshop, which is combined with general surgery, trauma surgery, hand surgery and interpretation of X-rays.”
Sourcing affordable medical devices and orthopaedic implants can often pose one of the biggest challenges for surgical capacity building projects like this. For hospitals, it is critical to find reliable partners who can provide them with affordable medical supplies. SALFA hospitals depend greatly on partner organisations for distribution of supplies, logistical efforts and funding. Medical Aid International – one of Arbutus Medical’s distribution partners – is a partner for context adapted surgical equipment and supply, and helps ensure delivery of the DrillCover technology.
According to Dr. Roth, the hospital at Antsirabe, which served as the training site for this program, focused on general surgery, gynaecology and obstetrics. Trauma accounted for only 10% of the cases. He points out that long bone fractures, which are common in other African countries, are rare in Madagascar because private transport is mainly using bicycles, and manpowered wooden carts play an important role in transportation. Traditionally patients with fractured limbs tend to search for treatment with traditional healers.
The Malagasy doctors were trained on how to use the Arbutus DrillCover system, which Dr. Roth had some prior experience with. “I first used this medical drill system in 2021 when I was with ‘Doctors Without Borders’ in the Central African Republic. It is very useful in environments where there are limited resources to buy power drills,” he said. “The Arbutus Medical Drill was introduced when I was there and it was very easy to teach people, who quickly got familiar with it and applied it correctly.”
Dr. Roth explained that there were theoretical and practical sessions to teach the doctors how to use this DrillCover technology. They were taught how to use the linen, pack the machine in the correct way and to adapt how to use the drill for different procedures, and practical sessions were used to place the external fixator on plastic bones.
The response of the SALFA doctors has been positive. Many doctors do not have a lot of exposure to orthopaedic trauma techniques and these workshops were received with great enthusiasm. Part of the lectures was how to make use of internet resources. For instance, ’Surgery Reference’ is a free app by AO Foundation, which helps doctors prepare the correct surgical procedure, by choosing the region and type of injury as well as the adapted implants. An innovation in itself, this app takes into account the medical equipment available to the doctor and sometimes gives suggestions even when there is no equipment available. This helps in daily surgical practice.
According to the Lancet Commission for Global Surgery, 5 billion people on the planet are without access to safe, affordable surgical and anaesthesia care, and 33 million individuals face catastrophic health expenditure every year due to payment for surgical and anaesthesia services. This is where innovations such as Arbutus Medical’s DrillCover technology can help in reducing the gaps in worldwide healthcare access and costs.
Dr. Roth first visited Madagascar in 1994, and has seen so much development in the country since then. “The SALFA hospital where we worked was very clean, especially when you take into account the limited resources. They have designed a new operating theatre, with the sterilisation unit located between the two operating rooms. This smart design allows for good hygiene and workflow. They have anaesthesia machines which work very well with in-built batteries, to cope with power cuts.” With all the progress, challenges remain, and will require ongoing effort to solve. “Dependency on bottled oxygen is an example of one issue to be looked at in the future,’’ said Dr Roth.
With all the work being done by the Lutheran church in Madagascar, positive changes are already being seen in the country’s medical system. Dr. Roth believes that by training doctors on new techniques and providing access to reliable equipment, the country is better equipped to give trauma victims access to basic treatment.
We would like to thank the entire team, composed of Dr. Volker Roth (orthopaedic and trauma surgeon), Dr. J. Zeller (general and thoracic surgeon), Dr. I. Zeller (radiologist) and Dr. N. Klaeber (hand surgeon), for their time and effort dedicated towards providing their expertise as a part of this program.