Initiatives for Outreach and Engagement
Many models for outreach and engagement have had a positive impact on the accessibility of surgery. Organizations participating in outreach are guided by a wide range of motivations and resources (Fig. 49-15). Some organizations are purely humanitarian and service oriented; others are primarily educational. Some even use the promise of healthcare to advance political, religious, or personal agendas.
Global surgery initiatives. (Illustration reproduced with permission from Intermountain Healthcare.)
Responding to the challenges of disparities, new generations of students, faculty, philanthropists, private industry leaders and policy makers have demonstrated a growing passion to address global surgery as part of global health. Prior to 1984 only 0.32% of physicians and 0.12% of nurses were involved in international health (either paid or volunteer).48 Recently, interest in global health has exploded among medical students in the United States. A 2009 survey indicated that 25% of U.S. medical students have traveled to LMICs for clinical and research electives. At some medical schools the number has risen to over 50%.49,50 In 2004, 40% of medical students in the United Kingdom spent their 6 to 12 week elective rotation in developing countries.51 A structured questionnaire was administered anonymously to all American College of Surgeons resident members. Approximately 94% of the respondents were general surgery residents, and 92% were interested in an international elective with many planning to volunteer in the future.52
Many patients have benefited from the multitude of service-oriented volunteer “missions” providing much needed surgical care that would otherwise have been unavailable. While volunteerism and medical missions are laudable activities, they are not a sustainable solution to long-term manpower shortages for health.53 Comprehensive initiatives are also necessary to engage local healthcare professionals and organizations, governments, and academic institutions to build capacity at home.54
Committed to maintaining international peace, developing friendly relations between nations, and promoting better standards of living (conquering hunger, disease, and illiteracy) and human rights, representatives from 51 nations in 1945 signed the United Nations Charter at the United Nations Conference on International Organization held in San Francisco, California.55 There are now 193 member states.56 The UN promotes a social justice agenda advocating for worldwide health, engagement of philanthropies and civil society in global health initiatives, and supports the Millennium DevelopmentGoals (MDGs).
Millennium Development Goals (MDGs)
Leaders from 189 countries gathered at the UN headquarters in September 2000 and agreed on eight specific “Millennium Development Goals” (Table 49-1).57 Some have argued that strengthening basic surgical care at district level hospitals is critical to reaching MDGs 4, 5, and 6 (reducing child and maternal mortality and halting and reversing the spread of AIDS).6,58 In poor countries, the enormous shortfalls in infrastructure, and human and material resources severely limits the capabilities to provide access to life-saving and life-changing services such as timely Cesarean-section, control of peri-partum hemorrhage, appropriate care for pediatric trauma, and treatment for a multitude of congenital diseases.3,59,60,61,62,63,64 While the evolution of public policy has been slow to accept surgical care as integral to poverty reduction and public healthcare, surgeons are actively campaigning for and joining the process of negotiating for inclusion of surgical care development into the new post-2015 to 2030 MDGs.65
Table 49-1Millennium development goals 2000–2015 ||Download (.pdf) Table 49-1 Millennium development goals 2000–2015
Reduce by half the number of people who suffer from hunger and whose income is < $ 1/ day
Provide universal primary education
Promote gender equality
Reduce mortality rate for children < 5 years by two-thirds
Reduce maternal mortality rate by three quarters
Halt and reverse the spread of AIDS, malaria, tuberculosis, and other major diseases
Improve the environment
Strengthen the global partnership for development.
World Health Organization (WHO)
The initial UN Conference in 1945 voted to establish a new international health organization. The Constitution of the World Health Organization (WHO) was approved and ratified in 1948.55 The first World Assembly in 1948 established malaria, tuberculosis, venereal diseases, maternal and child health, sanitary engineering, and nutrition as WHO priorities. One of the WHO’s greatest public health stories is the worldwide eradication of smallpox that began with the USSR proposal for the WHO-led program in 1958 culminating in the last identified case in Somalia in 1977.
While the disease burden from communicable diseases has abated in large part from these successful international cooperative interventions, little has been done to address the growing global burden of surgical disease. Despite the laudable 1978 Declaration of Alma Alta that expressed the need for urgent action for the world community to protect and promote the health for all people, the declaration did so by crowning primary health care as the key to achieving the goal of health for all—which was then accepted by the member countries in the World Health Organization.66 Although the Alma-Ata slogan “Health for all by 2000” did not materialize, it did galvanize efforts for global partnerships for healthcare improvements and poverty reduction.
The Violence and Injury Prevention Program (VIP) and the Global Initiative for Emergency and Essentials Surgical Care (GIEESC) are two programs related to surgery within the WHO that began before 2008. But, as a response to a growing recognition of the significant unmet surgical need, in 2008, the WHO for the first time included basic surgery as a component for community primary health care(Fig. 49-16).67
The Global Initiative for Emergency and Essential SurgicalCare (GIEESC)
The Clinical Procedures (CPR) team in the WHO Department of Essential Health Technologies (EHT) convened a multidisciplinary group of experts from various surgical disciplines, professionals and civic leaders from national and international organizations, and representative from various WHO departments in December 2005 in Geneva, Switzerland, to formally organize the GIEESC.68 GIEESC’s main aim was to assist member states with capacity strengthening in the safe and appropriate use of emergency and essential surgical care (procedures, equipment) at resource-limited healthcare facilities through training and education programs. The training program was built around the WHO “Integrated Management of Emergency and Essential Surgical Care (IMEESC)” tool kit.69 The tool kit included best practice protocols, guidelines on policies, training curriculum, emergency equipment, teaching slides, and monitoring and evaluation instructions. Additionally, low-cost editions of the manual Surgical Care at the District Hospital have been made available in local languages. A Mongolian edition facilitated early expansion of GIEESC throughout the country. Mongolia has improved basic infrastructure, human resources and capabilities; and the use of the tool kit system has led to its incorporation into the countrywide healthcare plan.70 (Box: Mongolia GIEESC)
The WHO situational analysis tool developed in 2007 to assess the availability of emergency and essential surgical care (EESC) at individual health facilities has been utilized in 35 different countries documenting the limited infrastructure, human resources, procedures, equipment and supplies available for even basic EESC.69 For example, there were no trained surgeons or anesthetists at 44 first referral hospitals in Mongolia.3 Only 66% of the facilities had electricity and 45% had running water (Fig. 49-17).
Most facilities lacked any policy for EESC, disaster preparedness, basic equipment to provide EESC, or any access to training for EESC. Adopting a health systems strengthening approach to rectify these glaring deficiencies, Mongolia implemented a nationwide EESC program involving 14 of the 21 provinces (Aimags) from 2004 to 2010 (Fig. 49-18).70 In six years, dramatic improvements in short-term process measures were identified using the WHO Monitoring and Process form: 57.1% increase in availability of emergency rooms; 59.1% increase in the supply of emergency tool kits; and a 73.6% increase in the recording of emergency cases (Figs. 49-19 and 49-20).70 More important, countrywide morbidity and mortality dropped significantly (Fig. 49-21).71
First Level (Soum) Hospital. (Photos reproduced with permission from Raymond R. Price MD. Layout reproduced with permission from Intermountain Healthcare.)
EESC Project: Mongolia 2004–2010. (Henry JA, Orgoi S, Govind S, Price RR, Lundeg G, Kehrer B. Strengthening Surgical Services at the Soum (First-referral) Hospital: The WHO Emergency and Essential Surgical Care (EESC) Program in Mongolia. World J Surg. 2012;36(10):2367, Fig. 2, With kind permission from Springer Science and Business Media.)
Surgical procedures performed 1-2 years Post-training (13 soum hospitals evaluated). (Henry JA, Orgoi S, Govind S, Price RR, Lundeg G, Kehrer B. Strengthening Surgical Services at the Soum (First-referral) Hospital: The WHO Emergency and Essential Surgical Care (EESC) Program in Mongolia. World J Surg. 2012;36(10):2367, Fig. 6, With kind permission from Springer Science and Business Media.)
Pilot Soum hospitals' evaluation 2 years post-training. (Henry JA, Orgoi S, Govind S, Price RR, Lundeg G, Kehrer B. Strengthening Surgical Services at the Soum (First-referral) Hospital: The WHO Emergency and Essential Surgical Care (EESC) Program in Mongolia. World J Surg. 2012;36(10):2367, Fig. 5, With kind permission from Springer Science and Business Media.)
Surgical morbidity and mortality: Mongolia 2001–2009.(Adapted from Indicators of Surgical Operation (Mongolia 2001– 2009). 2010 [cited 2011 November 2]; Available from: www.doh.gov.mn. Illustration reproduced with permission from Intermountain Healthcare.)
Violence and Injury Prevention (VIP)
The Violence and Injury Prevention (VIP) program promotes numerous activities to assist countries to prevent and mitigate the consequences of violence and injury.72 While injury prevention is paramount, VIP provides guidance for strengthening trauma systems in countries of all economic levels to improve emergency care and rehabilitation. VIP also encourages development of systematic data collection and analysis to better guide appropriate interventions. Prevention programs include the WHO Helmet initiative while the Essential Trauma Care Project (ESTC) creates standards for the care of injured patients and promotes systematic capacity building.
WHO Safe Surgery Saves Lives Initiative
Surgeons have always sought ways to prevent peri-operative complications. Aseptic technique, one of the greatest forms of prevention in surgical care, requires vigilant reinforcement to prevent serious wound infections. In resource-limited areas inadequate pre-, intra-, and post-operative monitoring, lack of critical medications, and poor documentation can be severely lacking placing patients at increased risk for serious complications. The WHO Safe Surgery Saves Lives Initiative is a worldwide attempt to prevent peri-operative complications.73
Deaths from surgery occur at 0.4% to 0.8% globally; however, they may exceed 5% to 10% in developing countries. There are about 1 million deaths and 7 million disabling complications related to surgery worldwide, 50% of which are estimated to be preventable. The WHO Safe Surgery Saves Lives initiative targets preventable surgical injuries.73 The initiative identified 10 basic and essential objectives that can help prevent peri-operative injuries (Table 49-2).74 A three-stage simple checklist (initiated as the patient entered the operating room, just before the procedure, and just prior to the patient leaving the room) implemented in 8 countries from high-, middle-, and low-income countries found a 50% reduction in the failure to meet basic safety standards resulting in a 50 % decrease in mortality (Fig. 49-22).75
Table 49-2Ten basic and essential objectives for safe surgery (WHO*) ||Download (.pdf) Table 49-2 Ten basic and essential objectives for safe surgery (WHO*)
1. Operate on the correct patient at the correct site
2. Use method known to prevent harm from anesthetic administration, while protecting the patient from pain
3. Recognize and effectively prepare for life-threatening loss of airway or respiratory function
4. Recognize and effectively prepare for risk of high blood loss
5. Avoid inducing any allergic or adverse drug reaction known to be a significant risk for the patient
6. Consistently use method known to minimize risk of surgical site infection
7. Prevent inadvertent retention of instruments or sponges in surgical wounds
8. Secure and accurately identify all surgical specimens
9. Effectively communicate and exchange critical patient information for the safe conduct of the operation
10. Establish routine surveillance of surgical capacity, volume, and results
Global Surgery and Public Health
Surgical care is increasingly recognized as an integral component of public health. Traditional public health teaching portrays surgery as the antithesis of public health: treating the individual instead of the community, reactionary instead of preventative, and too expensive especially for countries with developing economies. Yet in reality, surgery and public health priorities overlap in many areas (Fig. 49-23). For example, providing access to obstetrical care or birth attendants for every delivery could prevent the majority of vescio-vaginal fistulas and markedly decrease the most common cause of maternal death—hemorrhage—for entire communities.
Overlapping priorities of surgery and public health. (Illustration reproduced with permission from Intermountain Healthcare.)
Even after Learmonth presented his landmark lecture in 1949 “The Contributions of Surgery to Preventive Medicine” at the University of London’s Health Clark Lecture series, surgery has been neglected as a component of public health.7,76 The World Bank, in the 2006 Disease Priorities, 2nd edition, included its first chapter on surgery. An entire volume dedicated to surgical care is planned for the 3rd edition. There are three significant developments helping to accelerate the integration of surgery and public health:
Improved understanding of the burden of surgical disease and its significant component of the overall burden of global disease;
Recognition that surgery has a primary, secondary, and tertiary preventative role; and
Documentation that surgical care can be cost-effective for community-based healthcare.
Assigning Disease Priorities
Global surgery interventions can be prioritized to identify those conditions in which clinicians and public health professionals should collaborate most closely—targeting those diseases that impose the largest burden on a society and have a highly successful surgical outcome (Table 49-3).69,77 Levels defining public health burden, success, and feasibility have not been precisely defined. However, four broad, high-priority areas where surgery has an important role for public health interventions include: trauma care; obstetrical emergencies; acute-surgical emergencies; and nonacute surgical conditions that significantly affect the quality of life (Table 49-4).10
Table 49-3Prioritization of surgical conditions ||Download (.pdf) Table 49-3 Prioritization of surgical conditions
|PRIORITY* ||PUBLIC HEALTH BURDEN ||SURGICAL PROCEDURE SUCCESSFUL ||COST-EFFECTIVE AND FEASIBLE TO PROMOTE GLOBALLY |
|1 ||High ||Highly ||Highly |
|2 ||Moderate ||Moderately ||Moderately |
|3 ||Low ||Neither highly or moderately ||Low |
Table 49-4The role of surgery for public health strategies ||Download (.pdf) Table 49-4 The role of surgery for public health strategies
|Trauma care ||Prevention of death and chronic disability by the provision of timely, expert, and complete surgical care |
|Obstetrical emergencies ||Timely surgical intervention in obstructed labor, in pre- and post-partum hemorrhage, and other obstetrical complications |
|Acute surgical emergencies ||Provision of competent surgery to treat a wide range of emergency abdominal and nonabdominal conditions |
|Nonacute surgical conditions ||Surgical care for several elective conditions that have a significant effect on the quality of life such as cataract, otitis media, clubfoot, and hernias |
The Essential Trauma Care Project (EsTC) begun in 2001 is a collaboration effort between the International Association for Trauma Surgery and Intensive Care, an integrated society within the International Society of Surgery-Societe-Internationale Chirurgie (ISS-SIC) and the World Health Organization (WHO), specifically the Violence and Injury Prevention unit. The project culminated in a document that identified 11 core Essential Trauma Care services (identified as the “rights of the injured patient”) that should be available at all levels of healthcare facilities (Table 49-5).78 In addition, the document delineated 260 human and physical resources that should be available based on the type of facility (Table 49-6).
Table 49-5Essential trauma care services ||Download (.pdf) Table 49-5 Essential trauma care services
Obstructed airway appropriately maintained
Impaired breathing supported
Pneumothorax and hemothorax promptly diagnosed and treated
Bleeding promptly stopped (internal or external)
Shock recognized and treated appropriately (I.V. fluids)
Timely decompression of space occupying lesions to prevent secondary brain injury
Abdominal injuries diagnosed and promptly repaired (intestinal injuries and others)
Disabling extremity injuries corrected
Potentially unstable spine injuries identified and managed (early immobilization)
Minimize consequences of injuries by appropriate rehabilitative services
Medication to provide above services and relieve pain readily available
Table 49-6Airway management recommendations for physical and human resources based on type of facility(sample from EsTC*) ||Download (.pdf) Table 49-6 Airway management recommendations for physical and human resources based on type of facility(sample from EsTC*)
| ||FACILITY LEVEL |
|KNOWLEDGE AND SKILLS ||BASIC ||GENERAL PRACTITIONER ||SPECIALIST ||TERTIARY |
|Assessment of airway compromise ||E ||E ||E ||E |
|Manual maneuvers (chin lift, jaw thrust) ||E ||E ||E ||E |
|Insertion of oral or nasal airway ||D ||E ||E ||E |
|Endotracheal Intubation ||D ||D ||E ||E |
|Equipment and supplies || || || || |
|Oral or nasal airway ||D ||E ||E ||E |
|Laryngoscope ||D ||D ||E ||E |
|Endotracheal tube ||D ||D ||E ||E |
|Capnography ||I ||D ||D ||D |
The EsTC recommendations provide a cost-effective framework for LMICs to improve their trauma care. These recommendations have been used as a planning guide and as an advocacy statement. To catalyze strengthening trauma and emergency care in low-and middle-income countries, in 2007, the World Health Assembly (WHA) adopted a resolution on Emergency Care Systems (Resolution WHA 60.22).79,80 This first-ever WHA resolution dedicated specifically to trauma care highlights the importance accorded by world governments in caring for their injured.
Obstetrical and Other Acute Surgical Emergencies
Reduction of maternal deaths and long term disability are high priorities for the international community.81 Despite the 47% reduction in maternal deaths from 1990 to 2010, many women—mostly in LMICs—still die daily from preventable causes related to pregnancy and childbirth.82 The global maternal mortality ratio (the number of maternal deaths per 100,000 live births) declined by only 3.1% per year which is significantly less than the 5.5% reduction necessary to achieve MDG 5—to decrease maternal mortality by 75% by 2015.82 For every maternal death, 30 women are incapacitated by chronic problems that reduce their quality of life and ability to care for their families. High priority surgical procedures to improve maternal health include Cesarean-section, hysterectomy for postpartum bleeding and uterine rupture, management of ectopic pregnancy, and dilatation and curettage.77
About 90% of other acute surgical emergencies could be addressed by developing the capability to care for the 10 most common acute surgical conditions in any local region. While a few types of disease processes vary by geographical location, there are many that are universal, including appendicitis, strangulated hernia, small bowel obstruction, perforated peptic ulcer, fractures, lacerations, and wounds.
Nonacute Surgical Conditions
Even common nonacute conditions can have significant impact on the quality of life. Hernias can prevent otherwise healthy individuals from working, especially in societies where the economy relies heavily on manual labor. Cleft lip and cleft palate deformities interfere with the ability to speak or eat properly and predispose affected individuals to chronic ear infections leading to hearing loss. Many live in isolation because social ostracism prevents them from attending school, marrying, or holding jobs.83 Plastic surgeons who pioneered global outreach for reconstructive procedures for cleft lip and palate opened the door for subsequent outreach by other specialties, including ophthalmology, orthopedics, general surgery, urology, and dentistry.84,85,86
The most common form of blindness is caused by cataracts. Cataracts decrease the quality of life and the socioeconomic status for both the blind person and his family. The fact that 90% of blind people no longer work, places extra burdens on the family members who care for them.87 The Himalayan Cataract Project (HCP) is a highly successful initiative focusing on cataracts in Asia and Africa. HCP priorities and measurable outcomes illustrates how combining key public health concepts with a comprehensive approach to surgical care creates a model for curing disease, building economies, and delivering hope in resource-poor areas.9 (Box: The Himalayan Cataract Project: A Sustainable Public Health Approach for Curing Blindness)
The Himalayan Cataract Project (HCP): A Sustainable Public Health Approach for Curing Blindness
According to the WHO criteria, 180 million people worldwide are visually disabled. Of that population, 45 million are classified as bilaterally blind; 90% live in the developing world where poor water quality, lack of sanitation, malnutrition, and inadequate services cause a higher incidence of eye disease.87 The most common cause of avoidable blindness in LMICs is cataract (50%). Nepal has one of the highest incidences of cataracts due to increased exposure to ultraviolet sunlight encountered at its higher elevations; 70% of curable blindness in Nepal is due to cataracts.88
In 1995, Sanduk Ruit joined forces with Geoffrey Tabin to establish the Himalayan Cataract Project (HCP). In the early 1990’s, difficult geography and lack of transportation, the cost of the intraocular lens, and lack of trained ophthalmologists, assistants, and nurses limited access to cataract surgery for the poor.
HCP developed and defined six priorities each with an associated public health principle and outcome measurements that provided the basis for assessing success and for implementing change (Fig. 49-24). HCP’s care model targeted the entire population of blind people with cataracts regardless of the ability to pay. Since most of the potential patients lived in remote areas, HCP found it imperative to take cataract surgery to the local communities. The Tilganga Institute of Ophthalmology (TIO) in Katmandu, Nepal, has served as a base from which over 100 doctors and100 ophthalmic assistants and nurses have been trained.89 Through the TIO and its outreach programs, over 2,573,000 people have been screened and more than 172,000 eye surgeries have been performed since 1994 (Fig. 49-25).89
The TIO developed an ophthalmology residency training program implementing standards set forth by the American Academy of Ophthalmology. In addition to the formal residency program for ophthalmologists, HCP established training programs for community eye care workers in a three-year Ophthalmic Assistant Training Program.
Ruit developed an innovative suture-less technique for cataract surgery yielding equivalent results to those in developed countries but also reproducible in resource-constrained areas. By redesigning the intraocular lens and mass producing it locally in Nepal for U.S. $4.00, Ruit and Tabin provided a low cost alternative to the higher-priced lens produced in developed countries. A local business—the Fred Hollows Intraocular Lens Factory—mass produces the lenses and helps support the local economy by introducing a new sustainable business locally.90
HCP also designed a socially acceptable method for cost-recovery that involves a sliding scale for payment: 45% of patients pay U.S. $120.00; 20% pay a smaller amount based on their economic situation; and 35% receive cataract surgery for free.
Himalayan cataract project priorities, public health principles, and outcome measurements. (Redrawn from Himalayan Cataract Project and Tilganga Eye Center, (Cureblindness.org) (82-84) by permission. Illustration reproduced with permission from Intermountain Healthcare.)
Eye surgeries Tilganga eye center and outreach. (Redrawn from Himalayan Cataract Project and Tilganga Eye Center, (Cureblindness.org) (82-84) by permission. Illustration reproduced with permission from Intermountain Healthcare.)
Surgery for cancer in public health plays a role not only for curative surgery, but also for early diagnosis, prevention, and palliation.19,91,92,93 Solid tumors, in their early stages, presents insidiously as a nonacute surgical problem. Due to cancer’s recent recognition as a leading cause of death, cancer has been identified as a health priority in LMICs. Most solid tumors are incurable without surgery and at a minimum require surgical excision of the primary lesion.91
It is often not appreciated that surgeons provide a significant amount of primary care and are the principle providers involved in endoscopic screening and treatment of gastrointestinal tumors in LMICs. In countries without specialized services, low-cost and effective treatment options combining early prevention and treatment with off-patent drug use have led to coverage of cancer treatment in several middle-income countries’ national health insurance plans.19 Cancer care provides significant opportunity for including surgery in community-wide public health programs as a high priority according to the prioritization model; cancer has a high public health burden, is treated with highly successful procedures, and can be cost-effective and feasible globally. In 2009, a coalition of leaders in cancer care and public health organized the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTFCCC).94 GTFCCC’s mission is to expand access to cancer prevention, detection, and care in LMICs. Successful partnerships have already been entered into Haiti, Rwanda, Mexico, Malawi, and Jordan.
The Preventive Role of Surgery
Surgery plays a significant role at all levels of prevention of disease (Table 49-7). Trying to disassociate treatment from prevention presents challenges. Treatments can also be a form of prevention. For example, one of the root causes for the development of a vesico-vaginal fistula is lack of access to appropriate peri-partum care. Expeditiously performing a Cesarean-section (a form of secondary prevention) for obstructed labor primarily prevents the development of vesico-vaginal fistulas (primarily preventing the development of a different disease).
Table 49-7Prevention strategies ||Download (.pdf) Table 49-7 Prevention strategies
|PREVENTION STRATEGY ||TARGET ||GOAL |
|1. Primary ||Root causes of disease ||Eliminate or reduce risk of developing illness |
|2. Secondary ||Illness or disease at earliest stages ||Limit progression of disease |
|3. Tertiary ||Disease at later stages ||Cure or limit the effect of existing disease |
The surgeon’s role for disease prevention in the developing world is in its infancy of realization. Diseases commonly present in very late stages in LMICs and in disadvantaged populations in developed countries. Many morbid conditions could have been cured while localized in their earlier stages and likely eradicated by a local surgical procedure. Early recognition and treatment of surgically correctable diseases is a critical preventive role for surgery. Many surgical procedures are not only a form of tertiary prevention, but are also forms of primary prevention (Table 49-8).91
Table 49-8The role of surgery for primary prevention of cancer ||Download (.pdf) Table 49-8 The role of surgery for primary prevention of cancer
|TERTIARY SURGICAL PROCEDURE ||PRIMARY CANCERPREVENTED |
|Breast lumpectomy for ductal carcinoma in situ ||Breast |
|Colonoscopic polypectomy ||Colon |
|Colposcopy and excision ||Cervical |
|Resection of actinic keratosis ||Skin |
|Resection of leukoplakia and erythroplakia ||Oral |
Cost-effectiveness of Surgical Care
Funders in healthcare look for measurable return on their investments. While comparison of outcomes and objective measures would be ideal, reality demonstrates that healthcare budgets more commonly are dictated by politics rather than actual need. Nevertheless, in a world of limited resources and tightening budgets for healthcare, cost-effective analysis of various options for intervention are critical for policy makers. Comparing various options that have different outcomes is an approach called cost-utility analysis (CUA). Surgical interventions can be evaluated by specific diseases or conditions, or by systems or services required to support the delivery of surgical care. In 1990, the World Bank defined the Disability Adjusted Life Year (DALY) as the sum of Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences. (DALY = YLL + YLD). Evaluating the cost per DALY averted is one approach for comparing the cost-utility between medical and surgical interventions. Recent surgical cost/DALY studies identifying the cost-effectiveness of various types of surgical care have allowed surgical initiatives to be considered when prioritizing public health initiatives.
The World Bank arbitrarily defined U.S. $100/DALY averted per day in low-income countries as highly cost-effective. Compared to other public health initiatives, developing basic and emergency surgical care at the district level hospital is as cost-effective as or more so than typical public health programs such as retroviral treatments for HIV/AIDS or immunization for measles (Table 49-9).95,96,97,98,99
Table 49-9Cost effectiveness of public health measures ||Download (.pdf) Table 49-9 Cost effectiveness of public health measures
|PUBLIC HEALTH INTERVENTION ||COST-EFFECTIVENESS (U.S. $/DALY* AVERTED) |
|Rapid impact package for neglected tropical diseases ||2–9a |
|Measles vaccination ||5a |
|Basic surgical services district hospital ||11–33a |
|Antiviral therapy for HIV ||300–500a |
|Lichtenstein hernia repair with mosquito net mesh Western Ghana ||12b |
|Lichtenstein hernia repair with polypropylene or mosquito net Ecuador ||78c |
|Emergency systems for Caesarean delivery ||304d |
|Cataract surgery ||57e |
Using the WHO’s cost-effectiveness standards, investing in emergency obstetrical systems, including timely Caesarean delivery can also be considered “highly cost-effective” for 48 of 49 countries in which there are currently inadequate numbers of Cesarean deliveries100,101. The median cost per DALY averted by Cesarean-section was $304. In addition, the cost-benefit ratio in 46 of 49 countries was >1, suggesting that investment in Caesarean delivery is a viable economic proposition.
Inguinal hernia repair is one of the most common operations performed worldwide. Tension-free inguinal hernia repairs performed with mosquito netting or polypropylene mesh was cost-effective in Western Ecuador and Western Ghana ($78.18/ DALY and $12.88/ DALY averted, respectively).96,102 Using mosquito netting in India was 3700 times cheaper than using traditional polypropylene mesh.103
Factors Affecting Utilization and Outcome for Surgical Care
There are three major factors that severely limit utilization of surgical services:
socioeconomic and cultural
accessibility of facilities and
quality of care (Fig. 49-26)104
Factors affecting utilization and outcome of surgical care. (Adapted from UNFPA United Nations Population Fund (UNFPA); Providing emergency obstetric and newborn care to all in need. [cited 2013 February 27]; Available from: http://www.unfpa.org/public/mothers/pid/4385. Illustration reproduced with permission from Intermountain Healthcare.)
The decision to seek timely care is affected by the costs associated with time off from work and inability to support the family during the absence, transportation and lodging, and the surgical services themselves. Cultural and religious traditions may define acceptability of various treatment options. For example, many people in Mongolia refuse to have surgery on Tuesdays as this is viewed as a “bad luck” day. Understanding local customs and cultural concerns can improve utilization of surgical services.
Austere environments, difficult terrain, and long distances from health care facilities significantly delay or prevent access to surgical care. Triage and transfer guidelines along with tele-medicine have the potential to mitigate the limitations of geography. However, without adequately trained care providers and support staff, the risk for poor outcomes is increased.
Recognizing these three important factors for increasing utilization and outcomes, Mongolia initiated a public health approach for the management of gallbladder disease incorporating minimally invasive surgery. (Box: The Public Health Approach to Management of Gallbladder Disease in Mongolia)
The Public Health Approach to Management of Gallbladder Disease in Mongolia
Mongolia, the most sparsely populated country in the world, covers a large geographic area nestled between China and Siberia.105 The austere environment with extremes of weather, dry deserts, and high mountains present significant obstacles for road building limiting transportation for patients in the vast rural areas (Fig. 49-27). Significant deficiencies in infrastructure, supplies, equipment, and human resources at primary healthcare facilities exist: sporadic electricity, no fully qualified surgeons or anesthesiologists, and less than half the facilities with running water.3 In 2006, Healthcare expenditures reached only U.S. $23.2 per capita.106,107
The second most common cause of inpatient morbidity in Mongolia has transitioned to gastrointestinal diseases with liver disease, appendicitis, and gallbladder disease the top three causes.108 While laparoscopic cholecystectomy was introduced in Mongolia in 1994, by 2005 only 2% of gallbladders were removed laparoscopically, and then, only in the capital city.109 A cohort study in 2005 comparing open with laparoscopic cholecystectomy by Dr. Sergelen, the chief of surgery at the Health Sciences University of Mongolia (HSUM), found the wound infection rate to be significantly lower, hospital stays shorter, and hospital expenditures 50% less with laparoscopy compared to open cholecystectomy.110 Dr. Sergelen formulated a plan to expand access to laparoscopic surgery throughout Mongolia. This plan targeted the three main areas affecting utilization and outcome.
a) Quality of Care Develop a laparoscopic training didactic and practical course to train surgical teams.
b) Accessibility of Quality Care Begin training surgical teams in the capital city, but then expand them to four carefully selected regional diagnostic treatment and referral centers (RDTRCs) in all four quadrants of the country.
c) Quality of Care Improve the surgical infrastructure for each facility.
d) Socioeconomic/Cultural Factors Educate the public on the increased benefits of laparoscopic surgery so they would initiate lobbying efforts demanding the government increase funding for these services.
e) Socioeconomic/Cultural Factors Educate government leaders about the need and benefit of laparoscopic cholecystectomy for the Mongolian people.
f) Quality of Care Expand the surgical residency to include laparoscopic training.
g) Accessibility and Quality Invite industry to offer cost-affordable supplies and replacement parts to sustain the laparoscopic equipment in Mongolia.
Laparoscopic cholecystectomy has been expanded within the capital city and established in the initial 4 key Regional Diagnostic and Treatment Referral Centers (RDTRCs) and an additional fifth regional hospital creating countrywide access to high-quality modern surgery for a regionally prevalent disease through a multinational partnership directed by the chief of surgery at HSUM (Fig. 49-28).105,111
As people began to see their neighbors return to functional ability faster with the laparoscopic approach, the Mongolian people developed increased trust in their healthcare providers and the quality of care they could receive. This led to not only an increase in laparoscopic cholecystectomy but an increase in open cholecystectomy and many other procedures (Fig. 49-29).105
The Mongolian surgical residency has been expanded to incorporate laparoscopic training. The MOH has committed to increase funding for laparoscopic cholecystectomy and change existing laws making it easier for hospitals to purchase their needed supplies.
Rural Ger. (Photo reproduced with permission from Michelle K. Price.)
Regional diagnostic treatment and referral centers of Mongolia (RDTRCs). (Illustration reproduced with permission from Intermountain Healthcare.)
Cholecystectomy trends in Mongolia. (Adapted from: Unursaikhan C. (2010). Information of biliary track surgery in Mongolia. Health Sciences University of Mongolia, unpublished data. Illustration reproduced with permission from Intermountain Healthcare.)
Advanced Surgical Care for Resource-Poor Areas
Limited financial, physical, and human resources, political and social conflicts, and austere environments cause many to believe that advanced surgical care is inappropriate in resource poor countries.77,112,113,114 Misconception of the needs and abilities of people in LMICs cause some policy makers to discount the desire of people worldwide for advanced surgical care.105 Developing these capabilities in resource-poor countries has the potential to decrease overall cost and actually develop the infrastructure necessary to entice physicians and other healthcare workers to remain in their own countries. Establishing advanced surgical care requires expertise and services that symbiotically support and improve general medical care. Therefore, many developing countries are actively building capacity and capability to provide the full spectrum of modern surgical care locally.115
As economies improve and the benefits of laparoscopic surgery for resource-poor areas become better delineated, patients and doctors, surgical societies, ministries of health, and industries are demanding the benefits of minimally invasive surgery for patients and communities.111,116,117,118,119,120,121, and122 The economic impact of laparoscopy may be even greater in LMICs than in developed countries.123 Worldwide surgeons have identified laparoscopic training as one of their greatest needs. In a recent survey, developing laparoscopic and endoscopic skills were identified as the most important skills desired by surgeons from the West Africa College of Surgeons (WACS) (Fig. 49-30).124
West African College of Surgeons: most desired skills. (Adapted from Trigen Survey WACS: Akporiaye L. (2010). Trigen Survey: West African College of Surgeon. Port-Harcourt: Unpublished data. Illustration reproduced with permission from Intermountain Healthcare.)
Transplantation is another area of great interest to people in poor countries partly because of the high prevalence of kidney failure and because chronic dialysis facilities are limited. Hepatoma and liver failure are very common in countries with a strong prevalence of hepatitis B and C. Transplantation has become the treatment of choice for end-stage kidney disease in developed countries as it dramatically improves the quality of life and increases survival rates compared to medical management.125 Yet, transplantation eludes most of the developing world. Initial attempts to transport critically ill patients from LMICs to developed countries for kidney transplantation were cost-prohibitive.126 With the alarming increase in the rate at which young people have been presenting with kidney disease in developing countries, the increased utilization placed on the few dialysis machines has been overwhelming.127 Dialysis units which previously were utilized three times a week, now operate 24 hours a day, 7 days a week, and cannot begin to provide the needed services to the multitudes needing treatment. Even programs to develop peritoneal dialysis cannot fully ease the demand.
The majority of kidney transplants in developing countries are from living related donation. Laparoscopic living related donation has the potential to increase the voluntary donor pool as patients have less postoperative pain, return to work and activities quicker, and have much better cosmesis than open surgery.128 Adapting to the limited resources, surgeons have described various cost-saving techniques to facilitate the laparoscopic approach in resource poor areas such as using endoclips instead of staplers for vascular control, modifications to the surgical approach, and suprapubic extraction of the kidney rather than endocatch removal.128,129,130
Academic institutions have historically pioneered discovery in disease causation and treatment. As globalization expands, academic surgical programs are beginning to respond by broadening their vision for an interdisciplinary and collaborative approach to research, education, development, and advocacy.131,132
Academic involvement in global surgery provides training for the next generation of surgical leaders. Leaders for the 21st century will need to know how to provide outstanding cost-effective clinical care for all environments. With a more global view, the significant advances in scientific knowledge and clinical practice realized through basic and clinical research will potentially provide solutions for access to surgical care for all patients worldwide. Partnering academic programs with NGOs provides another opportunity for collaboration. (Box: Academic Global Surgery Partnerships)
Academic Global Surgery Partnerships A. Global Health Equity Residency
"In 2012, Brigham and Women's Hospital (BWH) Center for Surgery and Public Health (CSPH) launched the Global Health Equity in Surgery (GHE-S) residency program. Related to its sister program in Internal Medicine at BWH, the GHE-S program seeks to create future leaders in academic global surgery through structured education, field work, research, and mentoring throughout the length of their surgical residency at BWH. During the research years, GHE residents engage in collaborative field-based programs and research that link and support many of BWH global surgery activities. Projects to date include: Understanding Trauma Epidemiology in Rwanda, Understanding Surgical Epidemiology of Burera District, Cost-Effectiveness analysis of the Team Heart global cardiac surgery program, and Breast cancer epidemiology of Rwanda.133” —Robert Riviello MD B. Rwanda Human Resources for Health (HRH) Program
“The Rwanda HRH program is an ambitious 7-year long, U.S. federally funded, collaborative program of the Rwanda Ministry of Health (MOH) and 13 U.S. academic medical centers and universities. HRH seeks to greatly expand and improve Rwanda’s health care workforce by strengthening national training programs of specialized physicians, nurses, oral health providers, and hospital managers by recruiting U.S. faculty educators to join the National University of Rwanda (NUR) training faculty. In year one of the program (August 2012–July 2103), BWH contributed the largest number of physician educators to the program, recruiting 40% of the U.S. HRH physician faculty, including 6 surgeons. These surgeons have worked closely with their Rwandan faculty counterparts to restructure and organize the NUR surgery residency program, including development of curriculum, organizing didactic and clinical teaching, and greatly strengthening resident supervision and mentorship133.” —Robert Riviello MD C. Coordinating Non-Governmental Organizations (NGO) and Academic Organizations: IVUmed
Nonprofit organizations (NGO) have filled a niche in establishing surgical care in countries where training centers and healthcare systems are historically non-existent or understaffed. More recently, professional organizations have developed a focus on specific diseases or patient groups and have become a resource for education and training in poor countries.
For more than 20 years, the IVUmed NGO has focused on urological education and hands-on training in Africa, Asia, and Latin America. IVUmed evolved from a need identified by plastic surgeons that had seen many children with hypospadias and other urological anomalies such as exstrophy, when providing care for children with cleft lip and palate. Adult surgeons were not trained in the delicate reconstruction of pediatric genitourinary anomalies, and pediatric surgeons were not trained in endoscopic or reconstructive urological surgery. The program has expanded to support training in all aspects of urological care, including adult reconstruction, oncology, and endoscopic management of stones and prostatic disease.
As a nonprofit organization, IVUmed is a partnership between surgeons, anesthesiologists and nurses, academic medical centers, urological professional associations, industry and the public with urologic surgery training in more than 20 countries. It also provides North American trainees scholarships to travel to low-resource countries to learn and to share knowledge gained in their own programs. Many former scholars become mentors for other residents when they complete their training. The sites with the longest collaborations have developed their own educational programs in general urology or subspecialty areas and are now providing advanced training and care locally (Fig. 49-31).
Training outcomes from NGO/academic partnership. (Reproduced with permission from IVUmed and Intermountain Healthcare.)
The ethics involved in working outside one’s own home country are complex. While a practitioner’s scope of practice is usually constrained by regulation in America and Europe, in many countries the limits of what one can do are neither regulated nor enforced. Guidelines for what should be done—where, and under what circumstances are beyond the expertise of some ministries of health. Some problems are so episodic that they are not anticipated, and few guidelines exist. For example, in natural disasters and emergencies, should any willing provider from any country be granted permission to provide care? Should specific disaster-related training be encouraged or required?134,135 In the non-acute setting, should practitioners not licensed or credentialed in their home environments be allowed to perform volunteer surgery in other countries? What entity should oversee the flow of volunteer practitioners? Can a standard set of guidelines meet the needs of most countries? Currently, there is little cross national agreement between state entities, like ministries of health and independent organizations and individuals. While many countries require at least temporary licensure, some do not. In many cases enforcement is inconsistent.
With respect to research, the poor historically have not received benefit from research performed on them. In international studies, even local collaborators have been left out of study design and publication.136 As Internet communications have improved, these lapses no longer are tolerated.137 Informed consent for surgical procedures, given in the appropriate language and respectful of local customs, are becoming more the norm. Few hospitals outside academic medical centers have institutional review boards (IRBs) to oversee the implementation and review of clinical research. In recent years, peer reviewed journals have become more mindful of attribution of credit, and authors are strongly encouraged to design and report studies with local input at all levels.
With regard to transplantation, many countries have laws against cadaveric transplants because of the very real concern for illegal marketing of organs. Even living-donor transplantation has seen effects of coercion in some regions and for some populations such as prisoners. Nevertheless, the need and popular desire for transplantation is accelerating acquisition of skills and technology to make transplantation available worldwide.138
Finally, what is considered ethical in one country or one community might be considered highly unethical in another. Consent for surgery may in one setting rest with the patient, but in another, with the community or family. And values about privacy vary markedly from region to region. Health information in many cultures is considered to be a community concern and not the personal property of an individual patient.
Innovation in Global Surgery
The pressing need for surgical care at all levels and the shortage of fully trained surgeons, anesthesiologists and support personnel, equipment and supplies means that opportunities abound for innovation. Innovations in education, including simulation, can potentially shorten the time necessary for learning technical skills. Gaming technology can potentially teach algorithms for decision making and interpretation of X-rays and ultrasounds. Telemedicine/telehealth has the potential to transform education through combinations of clinical case-based learning and massively open online courses (MOOC). The potential for education innovation in surgery beyond the apprenticeship system championed by Halsted in 1904 is vast.
Innovation that radically changes the way we do things, that changes a paradigm of a service or system is called “disruptive”; it abruptly changes an older and more expensive system in favor of a less expensive, more widely available technology or process. The ability for disruptive innovations to transform products and services into affordable realities requires three main factors (Fig. 49-32).139
Elements of disruptive innovation. (Redrawn with permission from Christensen CM, Grossman JH, Hwang J. The Innovator’s Prescription. New York: McGraw-Hill, 2009. Copyright © The McGraw-Hill Companies, Inc. Illustration reproduced with permission from Intermountain Healthcare.)
Regulations and standards that vary between countries and locales can facilitate or impede disruptive change. While disruptions often are not qualitatively superior to the status quo, they make the process both less expensive and more accessible, and through multiple iterations, ultimately improve quality as they cycle through the transformative process.
De-centralizing education, laboratory testing, and medical records have been made possible through Free and Open Source Software, apps, and devices such as smart phones, tablets, and laptop computers. Monitoring devices, laparoscopic instruments, and imaging devices designed for low resource environments have the potential to not only improve accessibility in poor countries, but also to radically reduce surgical costs in wealthy ones.