Global surgery: moving from the neglected stepchild to central aspect of global health

Hans Rosling rightly spread the message that the world is rapidly improving. The Millennium Development Goals successfully highlighted fundamental health problems and resulted in increased access to basic healthcare in low- and middle-income countries (LMIC) (1). But the recent global health discourse has missed out on conditions affecting billions (2). We call for an urgent paradigm shift and enlightenment of an overlooked topic in global health – surgery (3).

Story by: Anna Pettersson & Gustaf Drevin

THE SURGICAL DISEASE BURDEN IS A PUBLIC HEALTH ISSUE

Surgical conditions relate to all health sectors, from maternal health to trauma. Provision of surgical care is fundamental to strong health systems. Still, 5 billion people lack access to safe, affordable, and timely surgical care.

Conditions that in high-income countries are treatable can be fatal in LMIC. 95% of the unmet need for surgical care is found in LMIC. An estimated 17 million people died from conditions amenable by surgical intervention in 2010, compared to 3.8 million people dying from HIV/AIDS, tuberculosis, and malaria – combined (3).

If you thought that was worrisome, consider that the epidemiological transition towards non-communicable diseases such as cancer, diabetes, and cardiovascular disease will add to the backlog of conditions requiring surgical attention.

Still, we bet that you have read much more about the burden of infectious diseases than surgery in your global health reading. You might even perceive surgery as complex, expensive, and not practically feasible in LMIC – even professionals though so. Indeed, the head of the World Bank, Jim Yong Kim, and the global health legend, Paul Farmer, aptly named surgery “the neglected stepchild of global health” in 2008 (4). 

THE STATE OF GLOBAL SURGERY

But things are changing dramatically. Today, global surgery has a larger presence in the global health discourse. A report written by the Lancet Global Surgery Commission in 2015 effectively addressed critical knowledge gaps in this field (3). Modelling projects combined with empirical data produced rough but mind-blowing report of the state of surgical care in LMIC.

One third of the global disease burden can be addressed with surgical care – a steep increase from the previous estimation of 11% (3, 5). The commission further estimated that 1.5 million, or 7% of deaths in LMIC, can be directly averted with effective surgical intervention. But patients cannot access the surgery that is offered, or does not receive timely surgical care, mostly because of financial barriers. Up to 48 million people face catastrophic economic loss to pay for the direct and indirect medical costs connected to accessing surgery in LMIC (6).

Untreated surgical diseases will cost up to $13 trillion by 2030 just in lost economic productivity – but scaling up surgical platforms to prevent this would cost just $300 billion

Unsurprisingly, the countries accounting for the poorest 37% of the world’s population perform only 6% of surgeries (3). And, an additional 143 million surgical procedures are needed annually in LMIC, a 50% increase compared to the current 313 million operations annually (3). The unmet need is tremendous and the resources are missing – medical staff as well as equipment.  Surgeons, obstetricians, and anaesthesiologists are required to maximise health outcomes. Deficits are seen in basic equipment including anaesthesia machines, pulse oximeters, and even sutures (12). In addition, it is not uncommon for hospitals to lack fundamental requirements such as reliable electricity and running water.  Covering for the millions of procedures is mainly an issue of human and material resources – quite the challenge for already burdened health systems.

THE COMPELLING CASE FOR INVESTING IN SURGERY

The avenues for change are numerous. Surgery is surprisingly cost-effective, even comparable to public health interventions such as mosquito nets, hypertension treatment, and vaccinations (13). It prevents disease such as HIV through circumcision, cures cancers and injuries, and palliates chronic diseases (14).

Untreated surgical disease will cost up to $13 trillion by 2030 just in lost economic productivity – but scaling up surgical platforms to prevent this would cost just $300 billion (15). Surgery is a treatment modality that addresses a significant proportion of the global disease burden and shares common building blocks with the broader health system.

This means that scaling up of surgery improves provision and outcomes of care in many health sectors. Basically, surgery has to be incorporated into national health plans in LMIC and be offered free of charge. The return of this investment is great – in economics and in human health.

Photo: Magnus Endal, [email protected]

INCREASED RECOGNITION ON THE GLOBAL SCENE

So, global surgery has evolved into a field of research, advocacy, and policy-making (16). There was only scant empirical knowledge but the Lancet Global Surgery Commission acted in synergy with other milestones in 2015, such as a World Bank report called Disease Control Priorities and a World Health Assembly resolution calling for increased attention to global surgery.

Soon after the Lancet report, the World Health Assembly published a resolution calling for increased focus on global surgery and anaesthesia (18). This important acknowledgement put surgery right up on the global health agenda. The World Bank subsequently added five surgical metrics to its guiding document, the World Development Indicators (19). Zambia then became the world’s first country to adopt a National Surgical, Obstetric, and Anaesthesia Plan (NSOAP) (20). Surgery is no longer a “neglected stepchild”, but has made its way to the political negotiating tables and research foci of global health actors worldwide.

THE MOMENTUM OF GLOBAL SURGERY

So where does that leave us? Despite gains made to have surgery added to policy-makers’ to-do lists, we are nowhere near fulfilling these promises (do not misinterpret us: millions of people are still dying from the lack of basic surgery). But, recent research has started defining country-specific challenges to surgical care provision, barriers to accessing surgical care, and investigates the role of surgery in universal health coverage (21, 22). The academic space and potential of global surgery is huge.

The authors have worked with and can attest to the allure of global surgery. Anna has investigated the gender differences pertaining to access to and quality of general surgery in Uganda and Gustaf is currently enrolled in The Paul Farmer Program in Global Surgery and Social Change in Boston and has clinical and research experience from half a dozen African countries. We argue that global surgery despite its increased recognition is just an emerging public health issue and needs involvement of the next generations of academics and clinicians.

The scarcity and questionable quality of surgical data are a great challenge to the global surgery community and colleagues in LMIC. There is a huge need for more research and involvement of surgeons, nurses, midwives, anaesthesia officers, and public health specialists. We suggest that you contact academic actors in these professions at your university, hospital, or similar institutions. You can have a rewarding and instructive experience in joining the global surgery community. If you are a medical student at Karolinska, you might want to apply for the elective “Global Surgery” (2016) in your clinical years.

To conclude, we urge interested students to explore what role you can have. The global surgery community has far to go in achieving our promises to the populations we serve, and this will indeed be a fight for you to undertake, tomorrow, the day after, and possibly as a long-term commitment to populations that still die from conditions that are amendable with basic surgical care.

Links:

  1. Kruk ME, Pate M, Mullan Z. Introducing The Lancet Global Health Commission on High-Quality Health Systems in the SDG Era. Lancet Glob Health 2017;5(5):e480-e81. doi: 10.1016/S2214-109X(17)30101-8 [published Online First: 2017/03/18]
  2. Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health 2015;3(6):e316-23. doi: 10.1016/S2214-109X(15)70115-4 [published Online First: 2015/05/01]
  3. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569–624. doi: 10.1016/ [published Online First: April 27]
  4. Meara JG, Greenberg SLM. Global surgery as an equal partner in health: no longer the neglected stepchild. The Lancet Global Health 2015;3:S1-S2. doi: 10.1016/s2214-109x(15)70019-7
  5. Weiser TG, Regenbogen SE, Thompson KD, et al. An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 2008;372(9633):139-44. doi: 10.1016/S0140-6736(08)60878-8 [published Online First: 2008/06/28]
  6. Shrime MG, Dare AJ, Alkire BC, et al. Catastrophic expenditure to pay for surgery worldwide: a modelling study. The Lancet Global Health 2015;3:S38-S44. doi: 10.1016/s2214-109x(15)70085-9
  7. Specialist surgical workforce (per 100,000 population): The World Bank Group; 2017 [updated Not available.; cited 2017 November 25]. Available from: https://data.worldbank.org/indicator/SH.MED.SAOP.P5 accessed November 25 2017.
  8. Anderson GA, Ilcisin L, Abesiga L, et al. Surgical volume and postoperative mortality rate at a referral hospital in Western Uganda: Measuring the Lancet Commission on Global Surgery indicators in low-resource settings. Surgery 2017;161(6):1710-19. doi: 10.1016/j.surg.2017.01.009 [published Online First: 2017/03/06]
  9. Massenburg BB, Saluja S, Jenny HE, et al. Assessing the Brazilian surgical system with six surgical indicators: a descriptive and modelling study. BMJ Glob Health 2017;2(2):e000226. doi: 10.1136/bmjgh-2016-000226 [published Online First: 2017/06/08]
  10. Esquivel MM, Molina G, Uribe-Leitz T, et al. Proposed Minimum Rates of Surgery to Support Desirable Health Outcomes: An Observational Study Based on Three Strategies. World J Surg 2015;39(9):2126-31. doi: 10.1007/s00268-015-3092-7 [published Online First: 2015/05/15]
  11. Bolkan HA, von Schreeb J, Samai MM, et al. Rates of caesarean section and total volume of surgery in Sierra Leone: a retrospective survey. Lancet 2015;385 Suppl 2:S19. doi: 10.1016/S0140-6736(15)60814-5 [published Online First: 2015/08/28]
  12. Vaughan E, Sesay F, Chima A, et al. An Assessment of Surgical and Anesthesia Staff at 10 Government Hospitals in Sierra Leone. JAMA Surgery 2015;150(3):237-44. doi: 10.1001/jamasurg.2014.2246 [published Online First: 2015/01/22]
  13. Chao TE, Sharma K, Mandigo M, et al. Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis. Lancet Glob Health 2014;2(6):e334-45. doi: 10.1016/S2214-109X(14)70213-X [published Online First: 2014/08/12]
  14. Rose J, Weiser TG, Hider P, et al. Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate. Lancet Glob Health 2015;3 Suppl 2(52):S13-20. doi: 10.1016/S2214-109X(15)70087-2 [published Online First: 2015/05/01]
  15. Verguet Sp, Alkire BC, Bickler SW, et al. Timing and cost of scaling up surgical services in low-income and middle-income countries from 2012 to 2030. Lancet Glob Health 2015;3(52):10. doi: 10.1016/S2214-109X(15)70086-0
  16. Dare AJ, Grimes CE, Gillies R, et al. Global surgery: defining an emerging global health field. Lancet 2014;384(9961):2245-7. doi: 10.1016/S0140-6736(14)60237-3 [published Online First: 2014/05/24]
  17. Disease Control Priorities, Third Edition – Volume 1. Essential Surgery. Washington, DC: International Bank for Reconstruction and Development, The World Bank 2015.
  18. WHA 68.15 – Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. 2015
  19. Raykar NP, Ng-Kamstra JS, Bickler S, et al. New global surgical and anaesthesia indicators in the World Development Indicators dataset. BMJ Global Health 2016;2 doi: 10.1136/bmjgh-2016-000265
  20. Mukhopadhyay S, Lin Y, Mwaba P, et al. National surgical, obstetric, and anesthesia strategic plan development— the Zambian experience. 2017
  21. Shrime MG, Dare A, Alkire BC, et al. Global country-level comparison of the financial burden of surgery. BJS 2016;103:9. doi: 10.1002/bjs.10249
  22. Haider A, Scott JW, Gause CD, et al. Development of a Unifying Target and Consensus Indicators for Global Surgical Systems Strengthening: Proposed by the Global Alliance for Surgery, Obstetric, Trauma, and Anaesthesia Care (The G4 Alliance). World J Surg 2017 doi: 10.1007/s00268-017-4028-1 [published Online First: 2017/05/17]
This article was previously published in Medicor 2017 #4
Proofread by: Joanne Bakker

Leave a Reply