How can a holistic perspective benefit practitioners, patients, and the planet?

Alton Ajay Mathew, Medical University of Lodz, Year 5

Whipple me good!

Hands move across the skin, cutting smoothly.

The clean-shaven abdomen now pierced through.

Armed with scalpel and cautery:

exposing piss-tinged globules of fat,

blood squirting, scalpel advancing,

truncated beeps droning out the

gas-enabled breathing.

Each bolus ballooning the bank,

each autoclaved tool billed to this body.

Layers of lipid, sit comfortably over organs,

protective and thick, condensing

above intestines and stomach

and pancreas and liver,

once forming a spherical dome,

now punctured for this healing.

The cure lies

in this clinking,

in sterile metal

searing out cancers

but with a cost, ticketed to this theatre.

The surgeon and his team, wide-eyed, steady-handed

now digging. A large abdominal hole splayed

for the searching – a moment

glassed over by light. Brightness

cauterising the moment with a militaristic veracity.

Shifting speeds, from tossing and scooping

to precise palpating, this mine-hunting on frontlines.

A swift piercing freeing,

the dark, ebony fluid

leaking over organs, trickling

like sewage,

slow.

Scalpels and staplers and scissors,

continue removing these unwanted parts—

cancerous parts, full of malignance, a wildfire unfurling

through forests of cells, through thickets of tissues

within duodena and pancreata.

Once clumping, twice dividing

and multiplying in vain,

and wreaking havoc.

For many,

their health marred,

and for some, their wealth scarred.

The organs sit

innocently shining,

bathed in saline and blood, luminous.

Wriggling and writhing under gloves,

telling, now begging, the healing hand

to let them stay.

These diseased parts:

are they aching in disdain,

silently screaming in pain?

A pain no analgesic can help contain.

The pain upon separation

from their kith and kin of a fifty-nine years,

the parts now carefully cauterised away—

from their home, from where they once belonged.

A penny clinks for each connection

the cautery can fallow. Burning connections,

untying ties, gently anastomosing towards a restorative demise.

Concealing new cures under silken stitches,

under the fat and the flesh,

and the frisson of those fees.

A catharsis so clear, a theatre

dithering in fear—

moral instructions left for the living

in patching up, a parabolic lesson

for those who can still see,

so they may learn of the fate

of those behaving abnormally.

Gloves,

lights,

knives,

cut,

throw,

gone!

 

Reflection

Surgical care continues to be a coveted luxury. For many, the burden of disease inflicts fear beyond the threat of mortality. My advocacy efforts, in Global surgery within the InciSioN Surgical Network, have revealed the insidious inequities that influence healthcare access worldwide. For 33 million individuals from lower-middle income countries (LMICs), catastrophic health expenditure is a by-product of seeking basic surgical and anaesthesia care. [1]

Reflecting on my formative exposure to abdominal surgery in India, this poem was an ode to the Whipple procedure (Pancreaticoduodenectomy or PD). Observing this cancer resection imbued me with a sense of awe: but in retrospect, I have reworked the poem to reflect on Susan Sontag’s revolutionary essay “Illness as Metaphor” [2], and the financial encumbrances of disease entities.

Sontag’s essay deals with historical shifts in social attitudes towards illness. She textually references the works of academics and charts the complex journey of the schemas underpinning diseases. In reflecting on and prying apart the physiology and pathology, her unflinching exploration reveals how the human condition responds to disease. Focusing on tuberculosis and cancer, she elucidates that “Any disease that is treated as a mystery and acutely enough feared will be felt to be morally, if not literally, contagious” [2].

Unsurprisingly, our post-modern metaphors attributable to illness have also shifted. Financial ruin is the new contagion for the patient. Seeking surgical care may disconcert some more than the disease itself. Engelgau, Karan and Mahal, 2012 report the odds of suffering catastrophic expenditure is 168% higher in cancer patients than those with communicable diseases [3], and this may in turn contribute to the data suggesting patients may “avoid mandated treatment for fear of incurring costs” [4].

The core indicators of the 2014 Lancet Commission on Global Surgery (LCOGS) report pledges to address six facets, two of which focus on delivering protection against impoverishing and catastrophic expenditure [1]. This holistic Global surgery framework will engage national stakeholders to create comprehensive health systems that eliminate the myopic and unintegrated approach, prevalent in public health.  A 2019 study from a government tertiary centre in India found the mean expenditure for PD was USD 74,420 (PPP corrected); 76.5% of this sample incurred catastrophic expenditure [4]. Household impoverishment is a fact of life for those seeking life-saving surgery. This vicious cycle is perpetrated by a triad of high out-of-pocket expenditure, a lack of insurance and low government health expenditure.

Notions of disease have superfluously morphed over time. Sontag observes cancer was once a “demonic pregnancy”, part of a disease entity stemming from “passion” or lack thereof, and “striking and blighting the deepest cellular recesses”. To Sontag, cancer may even concord with the “economic catastrophe” of “advanced capitalism”, as it is “described in images that sum up the negative behaviour of twentieth-century homo economicus: abnormal growth” [2].

Whether poetic or pessimistic, Sontag’s analysis is pertinent, as we too are blighted, but by the pangs of a fractious, economically-skewed healthcare framework. Addressing global variations in healthcare must begin with integrating surgical and anaesthesia care, as it is certainly an “indivisible and indispensable part of healthcare” [1]. Though Enhanced Recovery after Surgery (ERAS) protocols have promoted a holistic approach to improving clinical outcomes [5], a recent survey of 236 surgeons found that only 61% use them in clinical practice. Unsurprisingly, the survey was overrepresented by the Global North, with 42% hailing from Europe and 21% from North America [6], highlighting the urgent need for trans-national holistic solutions.

The National Surgical plans proposed by the LCOGS would undeniably promote holism in healthcare. In moving from an individual diseases approach to forming resilient, integrated health systems, the myriad consequences of untreated surgical conditions can be remedied. The LCOGS report calls us to promote ‘broad-based health-systems solutions” with a priority on safe and affordable surgical care [1].

In addressing the financial aftermath of seeking surgical care, the collective experience can be drawn upon in redesigning systems, shifting from a consumption-heavy model to one that approaches patients and practitioners in a holistic framework. Global surgery promises to not only reduce premature death and disability, but more interestingly, boost communal welfare and economic productivity [1].

Sontag’s essay implies that all the metaphors we impose on cancer are a “vehicle for the large insufficiencies of [our own] culture” [2]. Similarly, my poem aims to explore the inseparable influence of modern-day medicine from the capitalist frameworks that may afflict patients. The magic of healthcare is increasingly marred by patients being subjected to more pain, past the point of their pathologies. Poetry, with its inherent metaphors, was an ideal tool to explore this tension between patient, practitioner, and the wider society at large. I personally believe it is time for us to promote Global surgery. Even if it may not be the ‘master key’ or the global health panacea we have yearned for, it is certainly a step in the right direction to building a future that guarantees holistic healthcare for all.

 

References

1. Meara JG, Leather AJM, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet [Internet]. 2015;386:569–624. Available from: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(15)60160-X/fulltext
2. Sontag, S. (2005). Illness as metaphor and AIDs and its metaphors. New York: Picador, pp.6–64.
3. Engelgau, M.M., Karan, A. and Mahal, A. (2012). The Economic impact of Non-communicable Diseases on households in India. Globalization and Health, 8(1), p.9. doi:https://doi.org/10.1186/1744-8603-8-9.
4. Basavaiah G, Rent PD, Rent EG, Sullivan R, Towne M, Bak M, et al. Financial Impact of Complex Cancer Surgery in India: A Study of Pancreatic Cancer. J Glob Oncol. 2018;4:1–9.
5. Melloul E, Lassen K, Roulin D, Grass F, Perinel J, Adham M, et al. Guidelines for Perioperative Care for Pancreatoduodenectomy: Enhanced Recovery After Surgery (ERAS) Recommendations 2019. World J Surg. 2020;
6. Groen J V, Henrar RB, Hanna Sawires RG, AlEassa E, Martini CH, Bonsing BA, et al. Pain management, fluid therapy and thromboprophylaxis after pancreatoduodenectomy: a worldwide survey among surgeons. HPB. 2022;24:558–67.