Paul Farmer and the new World Bank President Jim Kim called it the “neglected stepchild” of global health. Atul Gawande admitted his surprise, “I could not understand why the world was not seeing avoidable harm in surgery as a major danger to public health.” The global health agenda is moving forward at an astonishing pace, but surgery seems to only recently have begun substantially entering the picture. The typical medical access trends in the developing world- very few physicians, even fewer in rural areas, and even fewer than that when considering specialists- are all exacerbated when isolating the surgical subspecialties. Currently, estimates suggest that of the 234 million surgeries occurring annually, only 26% take place in the poorest countries accounting for 70% of the global population. Given the large number of nonsurgical interventions that are cheaper, quicker, and easier to administer, one must ask whether surgery is rightfully neglected in developing countries.
The numbers don’t seem to suggest so. In the paper referenced above, Farmer and Kim suggest that a lack of surgical interventions is responsible for up to 15% of global Disability Adjusted Life Years (DALY) and that surgical disease, in some settings, is in the top 15 causes of disability. Other estimates suggest that surgery is responsible for ~11% of the Global Burden of Disease. Moreover, obstructed labor, postpartum hemorrhage, and trauma from birth and road accidents are among the leading causes of death in low and middle income countries, all of which usually require surgical intervention.
Surgery has been neglected largely because most global health interventions have tended to focus on communicable diseases which have a larger potential to spread and threaten more people. Accordingly, less surgeons have entered the global medical arena, whereas fields such as infectious disease are far more globally linked.
Surgery has a special place in the Global South, particularly because it can primarily function as a vertical intervention that can be implemented through short-term medical trips that many organizations participate in. Thus, the potential impact of creating a larger and more interlinked global surgical network might be even greater than that of other medical fields that deal with chronic illnesses requiring a more horizontal approach. The Global Burden of Surgical Disease Working Group has already begun to create this network, but more such efforts need to take place around the world.
Currently, most surgeries are not covered by the public health system in developing nations, and poor people who are often in greatest need of surgeries simply cannot afford to enter the fee-for-service market. This is why it is especially important to increase the work of international NGOs, academic institutions, and charitable organizations who can partner to provide free surgical services.
My own experience with global surgery was through an internship with Unite for Sight, a US based NGO which provides free cataract surgeries to patients in India, Africa, and Latin America. The NGO utilized existing private hospitals, partnered with small eye clinics and specific physicians, and leveraged fundraising and donations from the US to provide cataract surgeries to patients from rural villages who had been virtually blind for years.
Another group I recently heard about is Lifebox, an NGO started by Atul Gawande that provides pulse oximeters at an affordable price to operating rooms in low-income hospitals around the world. I’ve included a video of Dr. Gawande explaining his NGO’s work above. We need more innovative systems and ideas such as these ones to begin filling the gap in surgical care.
Nonetheless, it is undeniable that surgical development in resource-poor settings is extremely difficult. The various conditions and items that a surgical intervention requires are far more difficult to provide than a quick vaccine or simple pill. Aside from the operating room, a blood bank, anesthesia machines, a laboratory, and uninterrupted electricity are all crucial and not always available in rural settings. Atul Gawande and others at the WHO designed a basic checklist (below) to help improve surgical success around the world. The use of the checklist has been shown to reduce surgical deaths by one-half and errors by one-third.
As Tollefson and Larrabee noted in a piece in the JAMA, there is still a lack of data on the unmet need that exists for surgical interventions. The plan of action that they call for includes four main steps:
Collecting data to assess the need more systematically
Measuring the effects of various surgical services on disability and mortality
Establishing benchmarks for quality of care
Of these future objectives, cost-effectivness jumps out the most problematic and least promising. Frankly speaking, operations are expensive. However, looking closely at data, we can make comparisons that put this metric into perspective: in Sierra Leone, the “cost of care/1 DALY averted” metric for surgical interventions was US $32.78 as compared to US $300-500 for antiretroviral therapy. Nonetheless, future studies need to be done on this utilizing more than solely DALYs, which are themselves not flawless measures.
In a paper published in the World Journal of Surgery, Bickler and Spiegel point out that the WHO has recently highlighted surgery as an imperative investment because obstetric emergencies and congenital deformaties are critical public health problems, there is a huge access gap in low and middle income countries for surgical care, and because surgery is slowly being shown to be more cost-effective than we initially thought. In the last few years, the WHO added surgery to its primary health care initiative, and has begun to address how best to incorporate surgical care into health systems as shown in the figure to the right, adapted from Bickler’s paper. Surgery must be a key aspect of global health advancement in the years to come and no longer a field thought of as too complex and expensive to be able to help the poor.