Module 1: Surgery as a Global Health Issue

Surgery has not always been considered a global health priority, but the global health community has recently recognized that surgical conditions form a significant burden of disease and have cost-effective interventions. A surgical condition is one that requires suture, incision, excision, manipulation, or other invasive procedures that usually require anesthesia. Surgical interventions play a major role in helping to prevent death and chronic disability for those suffering from injuries, obstetrical complications, emergency abdominal and non-abdominal conditions, and for those suffering from conditions that have a significant effect on quality of life, such as cataract and club foot.  “Surgery is at the end of the spectrum of the classic curative medical model and, as such, has not been routinely considered as part of the traditional public health model. However, no matter how successful prevention strategies are, surgical conditions will always account for a significant portion of a population’s disease burden, particularly in developing countries where conservative treatment is not readily available, where the incidence of trauma and obstetrical complications is high, and where there is a huge backlog of untreated surgical diseases.” (1) Increasing access to surgery, and improving the quality of surgical interventions, may also help to achieve many of the 2015 United Nations Millennium Development goals. Surgery has the potential to reduce child mortality (Goal 4) as well as improve maternal health (Goal 5) by treating obstetrical complications. Surgery can also help to tackle infectious diseases, including HIV through male circumcision. In addition, surgery may even help halve the number of people living in poverty (Goal 1) since surgical conditions often put people out of work. For example, a survey in Pakistan found that blindness, most commonly due to cataract, was associated with poverty.(2)

Though surgery is often the only solution to prevent disabilities and death from road traffic accidents, falls, burns, disasters, domestic violence, pregnancy related complications, infections and congenital defects, access to essential surgical services has yet to be included as part of the basic human right to health. (3)  Though the global health community has been more willing to recognize the importance and role of surgical care as an essential component of obstetrical care, it has not acknowledged the importance of increasing the availability of other surgical services to low and middle income countries.(4)

Historically, the global health community did not focus its efforts on surgical care because it was perceived as being excessively expensive, and there was fear that if surgical programs were supported, they would divert resources from more cost-effective population-based programs. For this reason, most organizations preferentially funded programs targeting infectious diseases, despite “increasing evidence that charts the vast global burden of surgical conditions and the fact that relatively simple, cost-effective and curative surgical procedures can avert disability and premature death from many life-threatening emergencies and other conditions.”(5) Thus, it is a misconception that surgical interventions are overly expensive, and in reality they can be very cost effective. For instance, the estimated cost of surgical DALY (disability adjusted life years) gained at a district hospital in Africa ranges from $19 to $102. In comparison, antiretroviral therapy for HIV infection is estimated to be $350-$1,494 per DALY averted.(6) Therefore, “there is little doubt that surgery has a role in public health based on burden of disease estimates, even if only emergency procedures for obstructed labor and trauma are considered. Existing data suggests that many surgical interventions would decrease burden at low cost.”(7)

The World Health Organization has recognized the importance of surgery to global health and have begun to identify low-cost essential operations that significantly reduce the burden of disease.  In 2005, the WHO established the Global Initiative for Emergency and Essential Surgical Care, which strives to strengthen the capacity to deliver effective emergency surgical care, as well as reduce death and disability from road traffic accidents, trauma, burns, pregnancy related complications and other disasters. In 2007, experts in surgery, anesthesia, health policy and epidemiology came together to form the Bellagio Essential Surgery Group. The group encourages surgeons to participate in advocacy and education and to partner with public health professionals. The importance of promoting surgery in the developing world is also corroborated by Partners in Health. In 1996, Partners in Health helped fund and build an operating room in Haiti, and with the help of Haitian doctors, the organization has developed a surgical care system at their partner hospital, Zanmi Lasante. (8) Thus, fortunately, “public health specialists now recognize not only that surgery has a preventive role, but also that surgical treatment provided in low-tech community hospitals is cost-effective.” (9) Public health workers have also recognized that access to essential surgery should exist within the right to health and that “the common perception that surgical care is merely a luxury in poor countries must be reconsidered and its essential role in global public health must be acknowledged. Anything less will ensure that the morbidity and mortality endured by millions of people in poor countries unable to access surgical care will continue to remain invisible to the rest of the world.”(10)

Footnotes

(1) Debas, H., Gosselin, R., McCord, C., Thind, A. “Surgery.” In Disease Control Priorities in Developing Countries. (Washington, D.C.: World Bank, 2006).

(2) PLoS Medicine Editors, “A Crucial Role For Surgery in Reaching the UN Millennium Development Goals.” PLoS Medicine. 5.8 (2008): 1165-1167.

(3) Bickler, S., and Rode, H. “Surgical Services for Children in Developing Countries.” Bulletin of the World Health Organization. 80.10 (2002).

(4) Debas, H., Gosselin, R., McCord, C., Thind, A. “Surgery.” In Disease Control Priorities in Developing Countries. (Washington, D.C.: World Bank, 2006).

(5) McQueen et. al. “Essential Surgery: Integral to the Right to Health.” Health and Human Rights in Practice. 12.1 (2010): 137-152.

(6) Luboga, S. “Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group.”  PLoS Med. 6.12 (2009).

(7) McQueen et. al. “Essential Surgery: Integral to the Right to Health.” Health and Human Rights in Practice. 12.1 (2010): 137-152.

(8) PLoS Medicine Editors, “A Crucial Role For Surgery in Reaching the UN Millennium Development Goals.” PLoS Medicine. 5.8 (2008): 1165-1167.

(9) Debas, H., Gosselin, R., McCord, C., Thind, A. “Surgery.” In Disease Control Priorities in Developing Countries. (Washington, D.C.: World Bank, 2006).

(10) Ozgediz, D., Jamison, D., Cherian, M., and McQueen, K. “The burden of surgical conditions and access to surgical care in low- and middle-income countries.” Bulletin of the World Health Organization. 86.8 (2008): 577-656.