Her curiosity led her to ask Doctors Without Borders for data on
surgeries conducted in its humanitarian projects in 12 war-torn
countries in Africa and the Middle East. Between 2008 and 2014, the
nonprofit organization performed the majority - 69 percent - of its
nearly 50,000 operations in those countries on men, Wren and her
“Working in low-income countries, primarily in sub-Saharan Africa,
it has become obvious to me that women are underrepresented in the
hospitals,” said Wren, professor and vice chair of surgery at
Stanford University School of Medicine in Stanford, California.
“I’m concerned that women are having less access to surgery in these
countries,” she said in a phone interview. “We don’t know causality
here. My hypothesis is we’re looking at a societal judgment about
how women are valued.”
The study analyzed surgical procedures from Doctors Without Borders
projects, which, unlike other healthcare facilities in the regions,
offer services for free. Most of the operations were performed in
Afghanistan, the Democratic Republic of the Congo, Pakistan and
South Sudan on civilians whose ages ranged from 1 to 105 years old.
In predominantly Muslim countries, men were 70 percent more likely
to have surgical interventions, the study found, although senior
author Wren believes the disparity likely stems not from religion
but from culture.
Not surprisingly, men more frequently were treated for violent
trauma, including injuries from bombs, gunshots and knives, Wren and
her colleagues report April 8th in the journal Surgery. But 73
percent of the interventions for nonviolent trauma, such as burns
and vehicle accidents, also were performed on men.
Dr. Barclay Stewart has seen far more male patients while working in
Ghana, Nepal, Kenya and South Sudan, and in a phone interview, he
said the study “sounds an alarm.”
“It comes at a time marked by the highest proportion of persons
displaced by conflict and disaster in history,” he said. “The study
should make us all concerned we’re not doing enough to be sure that
women receive equal surgical care as men, have equal access to
surgical care and have an equal understanding of conditions that
require surgical care.”
Stewart, a surgery resident at the University of Washington in
Seattle, was reluctant to draw conclusions from the study data.
Researchers were unable to tease out whether men were more in need
of surgical services; whether services were unavailable to women,
and if so, why; and whether women chose traditional healers over
western healthcare workers.
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The data excluded obstetric and gynecological procedures and
facilities, where women may be more comfortable seeking care, said
Stewart, who was not involved in the study.
Men and women both often must travel long distances at great expense
to get care in these areas of conflict, and once they arrive in a
facility, they need a relative or friend to attend to the kind of
tasks, such as feeding and linen-changing, assigned to hospital
staff in higher-income countries, Stewart said.
Women get more than half the operations in higher-income countries,
Wren said. She said she does not know what drives the gender
disparity in these areas during armed conflicts.
“But I think it’s the same value judgments that keep males in school
longer,” she said. “It’s all about gender-based value decisions.”
While healthcare may be less accessible to women than men during
armed conflict, today’s wars make accessing care challenging for
everyone, Stewart said.
“The war is happening on people’s front door steps. There are no
enemy lines. It’s all entangled with civilians, women and children,”
he said. “There’s so many barriers to care at all levels that
there’s no silver bullet to overcome it, particularly for women.”
“In several conflicts, civilians have been intentionally targeted to
demoralize an enemy,” Stewart said. “Civilians no longer have
security when seeking healthcare. Unfortunately, women often are
much less able to overcome the barriers to get the care when
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