When One Surgeon Leaves, a Disease Vanishes from the Record: Nigeria Study Reveals Hidden Surveillance Blind Spots

In a finding that should unsettle anyone who reads disease statistics at face value, researchers in Nigeria have documented what happens to a hospital's surveillance data when its only resident surgeon walks out the door: the disease does not disappear, but the record of it does. A natural experiment conducted across seven hospitals in Nasarawa State showed that the departure of a single surgeon in July 2024 was associated with the complete cessation of documented cases of typhoid intestinal perforation, a surgically managed complication of typhoid fever, at the affected facility. Meanwhile, hospitals that retained surgical capacity continued to log cases at steady rates throughout the same period.

The study, published in BMC Health Services Research as an open-access article, was led by Dogara Ashikeni, with Yakubu Boyi Ngwai and Adamu Ishaku Akyala as co-authors. It ran from January 2023 to December 2024 and was built around an unplanned event the researchers describe as a workforce capacity shock. It can only be definitively confirmed in the operating theatre, which makes its documented incidence uniquely dependent on the presence of a surgeon and on the theatre registers that record each confirmed case.

That dependence is precisely what made the condition a sensitive probe for measuring how workforce capacity shapes what health information systems can and cannot see. The team assembled a comparison group of seven hospitals drawn from the 23 in Nasarawa State: the secondary hospital with the resident surgeon who would later depart, five secondary hospitals served only by visiting surgeons, and one tertiary hospital with full-time employed surgeons serving as a control insulated from the shock. The primary outcome was the monthly documentation rate of surgically confirmed typhoid intestinal perforation, extracted from theatre registers and compared across pre-departure and post-departure periods using Fisher's exact test and exact Poisson tests, methods suited to small counts and rare events.

The numbers tell a stark story. In the 18 months before the departure, the affected hospital documented 13 cases, a rate of 0.72 per month. In the six months after, it documented zero cases, a rate of 0.00 per month.

The incidence rate ratio was 0.00, with a 95 percent confidence interval of 0.00 to 0.98 and a p-value of 0.048, a statistically significant drop. A condition that had appeared in the hospital's records roughly every six weeks vanished from those records the moment the surgical capacity left the building. Crucially, the comparison facilities showed no such collapse.

The five visiting-surgeon hospitals documented 16 cases in total, with stable rates: 0.61 per month before the shock, based on 11 cases over 18 months, and 0.83 per month after, based on 5 cases over 6 months, an incidence rate ratio of 1.36 with a 95 percent confidence interval of 0.37 to 4.26 and a p-value of 0.567. The tertiary hospital recorded 148 cases over the full 24 months, an overall rate of 6.17 per month, split between 6.11 per month before and 6.33 per month after, an incidence rate ratio of 1.04 with a 95 percent confidence interval of 0.70 to 1.51 and a p-value of 0.850. The regional disease burden did not evaporate in July 2024; only its visibility at one facility did.

The study also asked the people who generate the records. In a cross-sectional survey of 440 healthcare providers, 433 responded, a response rate of 98.4 percent, and 78.5 percent agreed that workforce shortages reduce documentation of surgical cases. This perception data lends qualitative weight to the quantitative signal from the theatre registers, suggesting the pattern reflects a widely understood operational reality among frontline clinicians.

The authors frame the findings within a broader problem in global health data. Workforce shortages are well recognized as a weakness of health systems in low- and middle-income countries, but existing research has focused mainly on clinical outcomes rather than on how staffing losses distort the generation of surveillance data itself. From this observation, the team proposes what they call the GH Doma Principle: health information systems should include workforce capacity as a surveillance denominator.

A facility reporting zero cases of a surgically confirmed condition should not automatically be interpreted as having zero disease burden without consideration of its organizational capacity. A zero in the data column, in this framing, is not necessarily a measurement of disease absence but potentially a measurement of surgical absence. The evidence, drawn from a single affected facility and a modest number of pre-departure cases, carries inherent limitations of scale and geography, and the authors present it as a natural experiment rather than a definitive causal demonstration across all settings.

Even so, the pattern is difficult to dismiss: documentation continued uninterrupted at the tertiary control and the visiting-surgeon hospitals while stopping completely at the facility that lost its surgeon. For policymakers weighing surveillance investments in low- and middle-income countries, the message is that infrastructure alone cannot ensure reliable data. Health investments, the authors argue, must prioritize workforce retention if surveillance systems are to reflect the true burden of disease rather than the fluctuating capacity of the institutions tasked with finding it.

Subject of Research: The effect of health workforce capacity shocks on surgical disease surveillance documentation in Nigerian hospitals

Article Title: Health workforce capacity shocks reduce surveillance visibility: natural experiment evidence from a secondary hospital in Nigeria

Article References: Ashikeni, D., Ngwai, Y. B., & Akyala, A. I. (2026). Health workforce capacity shocks reduce surveillance visibility: natural experiment evidence from a secondary hospital in Nigeria. BMC Health Services Research. https://doi.org/10.1186/s12913-026-15463-5

Image Credits: AI Generated

DOI: 10.1186/s12913-026-15463-5

Keywords: health workforce, disease surveillance, typhoid intestinal perforation, Nigeria, natural experiment, health information systems, surgical capacity, LMIC health systems, workforce retention, hospital documentation, Nasarawa State, BMC Health Services Research