The United States has approximately 27,000 active practicing orthopedic surgeons to serve its population of 332 million, equating to roughly 1 orthopedic surgeon per 12,000 people. Despite the existence of nearly 200 training programs across the US, which annually produce between 850 to 900 new orthopedic surgeons, the demand on practicing surgeons is anticipated to rise over the next decade. This is due to the ongoing increase in musculoskeletal complaints within the aging US population.
Now contrast these numbers with those from Ghana. Ghana has a population roughly 10 times smaller than the US at about 32 million people, yet has significantly fewer orthopedic surgeons, estimated to be between 50 to 100 in total across the entire country. This translates to approximately 1 orthopedic surgeon per 425,000 people. This ratio is fairly consistent across Sub-Saharan Africa, where the majority of countries have ratios of one orthopedic surgeon to between half a million and one million people. Demand for these surgeons is exceptionally high due to the prevalent occurrence of road traffic accidents and other traumatic injuries, which account for a large proportion of all orthopedic surgical cases in the region (95% or more in some areas). The discrepancy between the two sets of numbers is stark.
To reach the equivalent of US population coverage, Ghana would require around 1,500 orthopedic surgeons. That’s nearly 20 times their current number. However, the training pipeline is starting to expand. In 2019 they had just 4 programs producing around 4 new surgeons a year. As of the start of 2024, Ghana now has 6 programs across the country producing around ~10 new orthopedic surgeons each year.
Progress is underway, but establishing an effective training center poses significant challenges. Several key aspects are essential for any orthopedic training program to succeed. Firstly, a hospital with sufficient supplies and staff is imperative to support orthopedic operating rooms and clinics. Secondly, highly trained faculty members who are willing and capable of teaching in addition to their normal clinical responsibilities are essential, alongside a steady influx of motivated trainees eager to learn. Finally, like most surgical specialties, an ample number of patients are required to ensure that all trainees can attain competency across a spectrum of orthopedic procedures. Failure in any one of these three pillars can hinder the mission of a training program. While I've started to delve deeper into this area and aspire to work in it in the future, for now, I'd like to center this post on another innovative solution being implemented in Ghana: collaborating with traditional bonesetters.
Traditional bonesetters are quite prevalent in Ghana and certain other areas around the world. They are a form of natural healer, employing methods that have been passed down, usually through families, for generations. While exact numbers are difficult to ascertain, they far outnumber trained orthopedic surgeons, particularly outside of the largest cities of Accra and Kumasi. Given their prevalence, they likely provide the vast majority of fracture care in Ghana. In fact, one study in Nigeria found that 85% of patients with fractures reported having used a traditional bonesetter. The reason for this is likely multifaceted, but interviews with those who have utilized these healers in Ghana identified more affordable care, cultural beliefs, and faster service to among the main reasons.
Given this unique situation, some argue that traditional bonesetters could play significant roles in Ghana's musculoskeletal care pathway. A study conducted in Ghana revealed that while the majority of bonesetters (67.9%) lacked formal education, nearly all interviewed (96.4%) expressed interest in training courses related to fracture management. Similar initiatives have proven successful in other specialties of medicine, including the incorporation of traditional birth attendants into the maternal and child healthcare systems in Ghana.
In response, Ghanaian orthopedic surgeons like Dr. Dominic Konadu-Yeboah and others have sought to better understand this group and evaluate their potential integration into a more structured care pathway. Their initial study involved enrolling traditional bonesetters in a four-day workshop focused on basic fracture management using local tools. The workshop emphasized specific fractures suitable for non-operative management by bonesetters and identified types of injuries, such as open fractures, necessitating urgent referral. The results are promising so far, with marked knowledge retention 6 months after the workshop and dozens of patients with more severe injuries being successfully referred to orthopedic surgeons.
This innovative approach appears to be yielding positive results. However, future studies and initiatives will be necessary to assess the extent to which this strategy can alleviate the burden of orthopedic injuries. Nonetheless, it represents a promising advancement in providing safe and effective musculoskeletal healthcare in a region that direly needs it while serving as a vital interim measure as more orthopedic surgery training programs are established and the pipeline of practicing surgeons is expanded.
Till next time,
Jamieson
P.S.
I hope you learned a little something! I just wanted to give a big shoutout to the many orthopedic residents and consultants at Korle Bu who shared their knowledge and perspectives with me for this piece. At the time of this writing, I have just 3 more days of my rotation at Korle Bu before I head back to the US for my final classes and Match day. I have learned an immense amount from everyone at Korle Bu and I am thankful for their time and energy!
Enjoy some photos from a recent weekend trip out to Cape Coast.