Wednesday, September 23, 2015

Surgery in Global Health: Not an Open-and-Closed Case

Imagine a scene in which ‘global health’ is occurring. What do we see? Perhaps a physician is down on bended knee, delivering vaccines to small black children, set against a blurred backdrop of village. Or we see looming figures in blue Hazmat suits hanging an IV bag to rehydrate an Ebola patient. Maybe a community health worker sits cross-legged among a group of women discussing pregnancy and distributing prenatal vitamins in sealed pink pouches. We don’t initially think of surgery. Increasingly, however, the scene of ‘global health’ will be set in a windowless sterile room, its providers will wear green masks and gowns, and its patients will receive life-saving laparotomies, open fracture treatments, and caesarean sections. Surgical services are greatly needed across low- and-middle income countries, and could reduce the global burden of disease by an estimated 77.2 million disability-adjusted life-years annually (Lancet Commission 2015). However there are numerous challenges facing this growing field including difficulty of health system scaling, scarcity of training sites, difficulty obtaining equipment, and lack of inclusion under the traditional umbrella of global health.

Surgery is an atypical topic in global health. Global surgery has historically been overshadowed by
movements to eradicate certain communicable diseases and bolster community health - movements which focus on preventative measures, not surgery. Indeed, while the UN Millennium Development Goals and its 2015 revision focus extensively on combatting HIV/AIDs and reducing infant/mother mortality, neither document includes any mention of surgery (link here: That surgical interventions are absent from these goals is perplexing: increased access to caesarean delivery is demonstrated to reduce neonatal mortality by between 30-70% (Molina, Esquival ,Uribe-Leitz et al 2015). Considering that among the Millennium Development are reduce child mortality and improve maternal health, perhaps our picture of global health should include a surgeon?

Many voices are now calling attention the absence of surgery as a global health priority. Among these: Paul Farmer, Atul Gawande, and the Word Health Organization. Perhaps the most prominent voice is the landmark Lancet Commission on Global Surgery (2015). The Commission states that an estimated 16.9 million lives are lost each year from conditions that can be treated surgically (by comparison HIV/AIDS and tuberculosis claim 1.46 million and 1.17 million lives respectively). At the same time there is a vast inequality in the delivery of surgical services worldwide: 90% of global injury deaths occur in low-and middle-income countries (LMICs), while the poorest third of the world receives only 3% of its surgeries (Lancet 2015). These figures identify both a clear need and a vast inequality in surgical infrastructure globally. But is it necessary – or possible – to build infrastructure where needed?

To the first question, “is global surgery necessary?” To some observers, surgery seems an unnecessary byproduct of Western medicine: it is invasive, highly technical, and involves little patient autonomy (besides signing “X” on a consent form). Unnecessary surgery occurs frequently in the Western world where it is readily available, and the surgeons may become wealthy by gaming a fee-for-service system. So why should we impose this product of Western medical excess upon the non-Western world? The answer: because surgery, when used as a life-saving measure, is never unnecessary. In cases of trauma, appendicitis, and births requiring a cesarean section, surgery is truly needed to save a life. Surgery, whenever is the only treatment option, is by definition “necessary.”

To the second question “is global surgery possible?” Frankly, the cost associated with scaling up health systems infrastructure in LMICs to parity with US systems would be astronomical. While surgery itself is a very cost-effective intervention - which will come as a surprise to many - the investment in system strengthening for safe surgery would be expensive.  It would occur through academic partnerships with Western institutions. Presently, a number of US medical colleges have sustaining commitments to health systems in LMICs (i.e. UVA surgeons spend time in Rwanda training residents and developing surgery programs). This brings us to our final question, the million (or multi-billion) dollar question: who pays?

We all do, either by shouldering the global burden of disease, or paying for the health system
strengthening necessary to address this burden. This kind scale-up through sustaining partnerships is a pressing problem global health today. In sum, while a global need for surgical services is present, there remains an equal need for funding through sustainable partnerships. It is uncertain at this time whether or not these partnerships are attainable under present models of global health. Importantly, for global surgery to become viable, it should be prioritized by UN Development Goals. There are numerous conceptions that may prevent surgery from falling under the aegis of ‘global health,’ not the least of which holds surgery to be a luxury item misused by the Western healthcare system.  Our picture of global health may not include a gown or scalpel, but if we are serious about delivering necessary care to all people, we ought to consider sketching in a surgeon or two (or about 20,000 by the year 2030).

- Michael R. Novack

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