The Quest for Global Surgery: Advances and Challenges

Illustration by Caroline Cao

Illustration by Caroline Cao

Surgery is an integral component of health systems for all countries at all levels of development. It is required across all disease categories, at all stages of life and within all levels of care, from prevention to palliation. In the absence of surgical care, even easily treatable conditions may become fatal. Obstructed labour may result in death for both mother and infant, cleft lip and palate may become an impediment to normal growth and development for a child and a broken bone can lead to lifelong disability.

However, according to the Lancet Commission on Global Surgery, only 6 percent of the 313 million surgical procedures undertaken worldwide occur in the world’s poorest countries, where a third of the world’s population resides. A staggering 5 billion people— largely from poor, marginalized and rural populations— do not have access to adequate surgical care, and an estimated 143 million additional surgical procedures are required each year to prevent death and disability. There are a number of hurdles to overcome: the lack of money, the distance from a hospital that provides surgical care, lack of transportation, lack of medical personnel and lack of infrastructure such as operation theatres, medication, oxygen and blood transfusion. Even among those who do manage to access surgical care, 33 million people face catastrophic expenditures due to the costs of surgical and anesthesia care, while an additional 48 million face disastrous financial burdens that can be attributed to the non-medical costs of accessing surgical care.  

Given the changing epidemiological trends in low and middle income countries (LMICs), the burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases and injuries requiring surgical intervention is only projected to increase. Without immediate attention and scale up, the absence of surgical care will not only continue to result in preventable death and disability for millions, but it is also estimated to decrease the gross domestic product of LMICs by as much at 2.0% by 2030. Until recently, intellectual and monetary investment in global surgery has taken a backseat to the priority given to individual diseases in the public health discourse. While remarkable strides have been made in the endeavor of reducing death and disability due to certain conditions, mortality and morbidity due to conditions requiring surgery have increased in the world’s poorest regions, both in real terms and relative to other health gains.

However, the tides are changing. Surgical and anesthesia care has proven to be remarkably cost-effective in resource-poor settings such as in LMICs. According to the World Health Organization’s standards, delivery of surgical and anesthesia services at first-level (district) hospitals is just as cost-effective as other common public health interventions in LMICs such as childhood vaccines, HIV medicines and distribution of bed nets to prevent malaria. (1) Given the enormous economic consequences for both individuals and nations in the absence of access to surgical care and the demonstrated cost-effectiveness of intervention in this arena, surgical and anesthesia care is indeed a sound investment.

Galvanized by the findings and recommendations of the Lancet Commission on Global Surgery, the Program in Global Surgery and Social Change (PGSSC) works to strengthen surgical systems and produce leaders in healthcare systems around the world through research, advocacy and care delivery. The program is a collaborative effort between physicians, surgical residents, medical students and research associates from different countries and backgrounds. These individuals come from a variety of organizations including the Harvard teaching hospitals, the Department of Global Health and Social Medicine at Harvard Medical School, Boston Children’s Hospital and Partners In Health. (2)

According to Shivani Mitra, an alumnus of Washington University in St. Louis, who is currently working at the Boston’s Children’s Hospital under the guidance of oral and maxillofacial surgeon Dr. Salim Afshar, PGSSC functions in a “fast, accurate and efficient way” to correct global surgery inequalities by working on over 50 projects in seven different countries through the public and private sectors. These projects take the form of cataloging the surgical capacities of healthcare systems in different countries and making recommendations for improvement, encouraging policy makers to prioritize increasing availability and access to surgical care in their charters, conducting innovation workshops to involve people from various disciplines and training physician and public health personnel through the Paul Farmer Global Surgery Fellowships and Research Associate positions. Mitra stated that some of their most significant successes and ongoing ventures are the adoption of National Surgical, Obstetric and Anesthesia Plans in Zambia and Tanzania, the evaluation of neurosurgery and trauma care capacities in Haiti and workshops to inspire engineering students to help reduce costs and improve access through technological innovations in India.

In Mitra’s words, “The advantage is that governments are listening to us and we see a good impact, but there are some compliance issues.” Indeed, while momentous headway has been made, it is an uphill battle to challenge the prevailing misconception that surgery is a luxury that only the wealthy can afford. At the dawn of exciting scientific advances such as personalized medicine, gene therapy and robotic surgery, we cannot afford to neglect the millions of people who are dying due to entirely treatable conditions because they are systematically excluded from access to safe, affordable surgical and anesthesia care.

Edited by: Katrianna Urrea

Illustrated by: Caroline Cao

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