Serving the Developing World: DePuy Spine and Dr. William Horton

Most of us in the West live in an orthopedic bubble, taking for granted that the latest technology will be available if we need it. But for a Chinese farmer with a shoulder fracture, or an African mine worker with chronic foot pain, the best has (long been) yet to come. Change is in the air, however, because of the novel, worthy efforts of one extraordinary man and an equally extraordinary company.

In December 2009, Dr. William Horton, Professor Emeritus of Orthopaedic Surgery at Emory University, had to stop his work as a spine surgeon due to problems in both hands. But he was determined to continue working on his brainchild, The Emory Spine Center for Outreach and Medical Education (ESCOME).

Photo source: Dr. William HortonDr. Horton: “I founded ESCOME in 2008 with the goals being to educate physicians and help to establish spine care centers in developing countries. We began in China, in part because the medical infrastructure there was fairly established. About the time that I was considering where my new professional home would be after having to stop surgery, DePuy Spine, a Johnson & Johnson company, (already an ESCOME sponsor) approached me about an exemplary new program they were putting together. DePuy had made an unusual and bold corporate decision—they wanted to focus a significant amount of resources on helping the developing world. I was hired as an international medical education consultant and moved the ESCOME project to DePuy because I could see that the chances of the program having maximal impact and success would be much higher under the industry umbrella.”

And what about DePuy’s efforts gave Dr. Horton confidence? “I could see that the business executives at the highest corporate levels were seriously examining the risks and benefits of creating technology for the developing world and fully appreciated the role that education plays in elevating the level of care. DePuy had looked at several specialties but decided that international spine issues were so widespread that they merited special attention. DePuy Spine committed to doing a Chinese pilot project in November 2009.”

Determined to knock down barriers for those suffering around the world, the DePuy Spine team established three goals for its China program. Dr. Horton: “We are aiming for affordable and safe technologies that are intuitive enough so that healthcare professionals in developing countries with limited training can use them effectively. Additionally, we are optimizing training opportunities for doctors with strong fundamental skills but who work in quality second tier hospitals. Finally, we are wading through distribution issues in order to get affordable technology to people who need it.”

As for the first goal, engineers spent many a late night around the table evaluating product designs and asking,

Would this work in a Szechuan village?” Dr. Horton explains, “The basic goal is to take existing technologies and reverse engineer them such that the cost is half of what it would normally be.

A rural patient in a poor country has probably sold his last water buffalo to pay for his mother’s implants. Then if she develops a complication such as an infection, where is the money going to come from for the follow up treatment? This means that we also have to focus on technologies and processes that minimize the potential for complications.

"In a very real sense, the skilled, high-powered individuals leading this effort had to slow down, listen, and become learners. “In preparing the way to address our second goal—training surgeons—we had to learn the structure of Chinese healthcare. There are three tiers of patients: the wealthy, the middle class, and those in desperate poverty. Generally speaking, wealthy patients have ways to obtain excellent medical treatment, while those in the middle class have access to some medical services of inconsistent quality (although they live on the razor’s edge financially). Additionally, the skill set of medical professionals is quite variable, which makes for real challenges and opportunities with education. The best trained doctors are outstanding but treat only about 10% of the patients at the highest quality hospitals, while the second tier physicians care for 50-60% of the population in those hospitals, with the poorest third of the populace often going without any care.”

Despite its intense dedication and efforts, even DePuy Spine can’t wave a wand and alter the internal dynamics of a nation. But a determined team can make a difference by being strategic. “Many of these issues are so embedded in the healthcare system that there are things we just cannot do. We took a hard look at where we could actually improve people’s lives…and we decided to focus on training for the ‘second tier’ surgeons. We began by selecting a few leading Chinese surgeons with solid English skills to receive extremely valuable intensive training. They are becoming the future faculty for the courses that will be given largely in Chinese to those doctors in the second tier (where English cannot be relied on). These courses are designed for surgeons grappling with the issues of treatment indications, clinical decision making, and surgical technique. The courses involve 40-70 spine surgeons who present real cases they are struggling with. Over the next couple of years we and the Chinese faculty will observe the doctors’ effectiveness and address any weak spots in the training…then they should be ready to take the reins at the second tier hospitals in China.”

When working abroad, a nuanced and critical issue, says Dr. Horton, is language. “The well-meaning American surgeon who wants to work abroad can only go as far as language will take him or her. As a result, we decided to build our program using top tier Chinese surgeons who speak English well. The key to the program is that ultimately the teaching for tier two doctors will be in the Chinese language. More than anywhere else, when working with cadaver labs and techniques, language skills are vital where double meanings of words or complex vocabulary often interact."

"Maybe a well-meaning American teacher is explaining to a Chinese surgeon how to best retract the nerve root, saying ‘the retraction should be light, easy and intermittent.’ That student may not know the word ‘intermittent’ and may misinterpret the word ‘easy’ as ‘simple’ and ‘light’ as ‘illumination’—which all makes no sense.” 

So where are they now? “DePuy has established two teaching labs, one in central China and another in Shanghai with several courses for 2010 and 2011. We are addressing a twofold mission: one is to develop the top Chinese surgeons as faculty for the tier two teaching hospitals while also training them in such advanced procedures as cervical disc replacement and minimally invasive anterior lumbar corpectomy. The other goal is to help teach the ‘second tier’ surgeons how to do core spine procedures technically well. These particular courses are being taught in Chinese by the leading Chinese surgeons with two North American or European faculty there as guides and partners. Importantly, we have learned that if the courses are in English then only one third of what is said will actually get through to people. You lose the nuances, which as we all know can lead to problems.”

When dealing with the third leg of the stool—distribution—the team has to take into account local and national Chinese politics and market dynamics. Dr. Horton notes, “We can go at this project with gusto, but if we can’t find a way to work within the existing system then things won’t happen. Let’s say we have a really safe product that is half the cost of current products…we must have a way to get the product to the surgeons and patients who need them--otherwise the education will be of limited impact. Sometimes, secondary agendas and arrangements are often in play at the hospital, city or province level that may impede the distribution of affordable technologies. We are trying to address this.”

“And while in many cases those in the developing world are no longer sitting and waiting to get technology from the outside world, the average Chinese doctor and patient still recognize the differences in quality control and manufacturing standards. The bottom line is that in most cases, locally made, as opposed to foreign made, products will be used in tier two facilities until more affordable technologies are introduced. The doctors think, ‘OK, now I am trained in procedure X, but half of my patients can’t afford a name brand product, so I have to be able to offer them something.’ So they end up using an inferior device which can be really bad for patients.”

As for DePuy Spine, they are excited to be making progress on this challenging, but rewarding program. Debbie Williams, the company’s Director of Communication states, “We are truly dedicated to increasing access to care in developing countries. We’re scaling up professional, robust educational programs in China and matching these efforts to what specifically is needed by the surgeons and patients in that country.

China is our main focus initially, but as we move forward with our international education efforts we look forward to growth in other countries, such as our new training center in Brazil, and the one that is planned to open in India in 2011.

These programs will benefit patients throughout the developing world, building on the principles initiated in China, and incorporating features unique to each country as Dr. Horton and our entire education team refine the process.”