Chapter 49: Global Surgery

1. There are five major forces reshaping priorities and strat­egies for the globalization of surgical care:

   1. The epidemiologic transition of diseases

   2. The mobile nature of the world’s populations

   3. Ubiquitous information access

   4. A revolution for equity and human rights

   5. Recognition of the cost-effectiveness of surgical care

2. Understanding and addressing the necessary communication, energy and transportation technologies along with the underlying cultural context represent the foundation critical to implementing sustainable infrastructure necessary for appropriate surgical care.

3. The key components of the global surgery ecosystem include technology, education, community, healthcare, business, and multidisciplinary engagement between a variety of disciplines.

4. There has been a significant shift from communicable, maternal, neonatal, and nutritional causes to noncommunicable causes, many of which require surgical care.

5. Patients and their communities in low-middle income countries (LMICs) bear a much greater share of the burden of cancer than high-income countries.

6. Globally, trauma has become a leading cause of death and disability; 90% of trauma deaths occur in LMICs.

7. The burden of disease is greatest in areas where human resources—physicians, nurses, pharmacists, and other healthcare workers—are the least.

8. Surgery is gaining an increasingly recognized role for improving public health.

9. Surgery has a role in prevention as well as treatment.

10. The cost-effectiveness of various aspects of surgical care has allowed surgical initiatives to be included when prioritizing public health initiatives.

11. Developing advanced surgical 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.

12. Academic involvement in global surgery provides training for the next generation of surgical leaders.

13. Surgical innovations that consider cost as well as quality and design for challenging energy environments will foster equity in surgical care for LMICs.

Modern surgery can save lives, help expand economies, and offer hope to individuals and communities. Prior to the acceptance and availability of aseptic technique to prevent or decrease infections, and improved anesthesia for controlling pain, surgery as a specialty was held in very low esteem. Over the last 100 years, surgery has developed into an elite discipline that not only provides opportunities for curing certain diseases, but fulfills a special role in preventing and mitigating disability.

Yet, surgery is currently unavailable to most people worldwide. The vast majority—90%—of the world’s population receives only 10% of the surgical care delivered. Said another way, 90% of the world’s surgical resources are consumed by the most privileged 10% of the world’s population. More than 2 billion people lack access to even basic surgical care.¹ Very few surgical procedures occur in countries spending less than US $100/ person on health care per year compared to countries spending greater than U.S. $1000/ person (Fig. 49-1).²

Examples of disparities abound. In many countries, including the wealthiest, deep pockets of poverty coexist within cities replete with material resources. Tertiary level hospitals operate within eyesight of slums whose inhabitants have no access to even basic care. Most of the people without access—people in rural areas and in countries with poor infrastructure—are the very people most at risk for death or disability due to lack of surgical care. Often the poor accept and endure many painful and potentially correctable fatal conditions as a fact of life.^3,4,5,6 Care for trauma and obstetrical emergencies are considered basic surgical needs but are absent in many rural regions. Other chronic conditions—often equally debilitating—progress to death or serious disability due to lack of available, safe surgery and anesthesia.

Many factors contribute to the disparity in access to surgical care. Poverty, a primary risk factor for all types of diseases, is a major obstacle hindering access to surgery. Healthcare professionals, including surgeons, migrate from areas of need due to a lack of infrastructure (hospitals, roadways, and stable electrical sources), limited supplies and equipment, lack of human resources, few opportunities for professional development, and concerns for personal safety. Finally, the lack of information about the burden of surgical disease and surgery’s impact on communities has led to misconceptions of policy makers that quality surgical care is cost prohibitive and too complex to be seriously considered a viable conduit for improving global health.^7,8

Disparities in care and outcomes are multidimensional, and no simple solution exists to improve access to appropriate and affordable surgical care. Yet, five major forces are reshaping priorities and strategies leading the charge for the globalization of surgical care:

1. The epidemiologic transition of diseases from primarily infectious to more chronic conditions;

2. The mobile nature of the world’s populations allows more convenient travel opportunities for people to move freely between more isolated areas of the world leading to a more integrated global community;

3. Ubiquitous information access exponentially enabling universal participation in understanding and designing innovative opportunities for high-quality surgical care;

4. A revolution for equity and human rights where the world’s poor are demanding benefits to surgical care similar to those found in developed countries;

5. Recognition of the cost-effectiveness of surgical care, and its potential to build economies, demonstrating the potential value of, including surgery in global health strategies.^9,10

The potential benefits of surgical care for economic productivity are astounding. Considering that the annual economic loss from road traffic injuries alone exceeds U.S. $500 billion globally, a panel of expert economists at the Copenhagen Consensus of 2012, including four Nobel prize laureates, understandably ­prioritized strengthening surgical capacity as the eighth most cost-effective investment for addressing the world’s current most pressing problems.^8,11 Good health, which fosters productive economies and political stability, must include access to the full spectrum of health care, including surgical care to “advance the quality of life for billions of citizens around the world.”⁸

This chapter examines the need for expanding surgical care globally, explores some of the seemingly insurmountable challenges, and presents potential guiding concepts along with examples of successful strategies for sustainable surgical development.

Global Surgery Ecosystem

To understand how surgery fits into healthcare systems and to understand its unique needs, it is helpful to consider global surgery as an ecosystem. The emerging field of global surgery considers surgical care to be a fundamental component of global health. As a system with both local and international scope, global surgery encompasses not just the medical and technical aspects of surgical care but also the societal and environmental context in which surgery is performed. Surgery as an ecosystem considers the diverse but interrelated systems that must be functional for quality surgical care to be delivered. Only part of these systems falls within the traditional training of surgeons. Yet, modern surgical care requires these systems to work in a coordinated fashion to support three priorities critical for expanding surgery globally—accessibility, affordability, and innovation (Fig. 49-2). Global surgery is a way to consider a “systems-based practice” beyond a single hospital or community for the benefit of people worldwide. Many of the interrelated components of this surgical ecosystem originate outside the hospital.

Disparities in surgical care have geographical, socioeconomic, and cultural components. Most people who live in major cities in northern and western hemisphere countries take for granted a functioning energy grid. The development of energy beyond major cities has enabled many wealthier communities to imagine, and indeed, to expect healthcare to be available at all times and to be affordable. Yet, a lack of reliable energy sources is a major limiting factor. Communication and transportation technologies, for example, the mobile phone and air and ground travel, have dramatically progressed in high- and middle-income countries but are still rudimentary in poor countries. Many of the current disparities in health care, particularly surgical care, are due to the lack of penetration of these technologies. Understanding and addressing the necessary communication, energy and transportation deficits as well as the underlying cultural nuances are necessary to support the sustainable development of surgical care (Fig. 49-3).

Electricity is necessary for all modern surgery. Anesthesia monitoring, OR lighting, cautery, suction, and patient warming devices all require sources of electricity that are stable, without huge electrical surges. Only in the last 50 years or so could stable electricity be expected in most wealthy cities. However, in rural areas of even wealthy countries, electricity remains unpredictable (Fig. 49-4).

In poorer countries, the cost and availability of electricity is frequently the limiting factor for more advanced diagnostic and therapeutic technology—from laboratories that require refrigeration to radiology in all of its various branches. Modern design for surgical devices has, for the most part, not taken into account the wide range of energy environments where surgery is practiced. Fragile instruments and monitors that cannot survive the rigors of the real working environment limit the types of surgery that can be provided.

Components of the Global Surgery Ecosystem

Improvements in energy, transportation, and communication are critical to support the growth of six key components of surgical care (Fig. 49-5).⁹ While building capacity within each component is important, it is the interaction between the components that creates a functioning, sustainable system.

When surgeons think of surgery, they usually think in terms of science and hands-on technical expertise. However, global surgery requires a broader understanding of systems in other disciplines. Surgeons must work collaboratively with engineers and business leaders to develop technology that can function in lower resource environments. These innovations can provide a source of economic growth for the community, which in turn supports better health care.

No sustainable surgical system in the modern age can function without specialists in bioengineering, sterile process, supply chain, hospital safety and waste management. These often unappreciated colleagues make possible the daily practice of surgery. Similarly, specialists in anesthesia, nursing, and the diagnostic specialties of radiology, pathology, and laboratory services are fundamental to a fully functional surgical service.

Burden of Surgical Disease

Epidemiologic Transition of Disease

The population on Earth currently stands at more than 7 billion.While the rate of growth has slowed in recent years, projections estimate that the population will continue to grow to 9 billion by 2050.¹² When thinking about global surgery, it is helpful to step back from the individual and consider families, communities, and nations. Each entity has its unique cultural and economic history and geographic advantages or disadvantages. Each has its own system for addressing surgical care but operates within a larger ecosystem, including energy availability, telecommunications and social networks, an interdependent global economy, and local material resources.

Population characteristics are changing rapidly. According to United Nations estimates, the human population of the entire world is aging, even in low-income countries, and by 2050, 2 billion people will be over the age of 60. Currently, Asia is home to 55% of the world’s population over the age of 60.¹³ Until recently, infectious diseases dominated public health strategy. Now with major scourges like polio isolated to relatively small regions of the world and HIV and malaria decreasing in their relative impact worldwide, chronic diseases and their complications, as well as the effects of aging, are gaining dominance in health care needs. Many of these chronic diseases are best approached by surgery.

The lack of metrics and paucity of data identifying the unmet burden of surgical need in many countries have been obstacles facing global surgery initiatives. The 2010 Global Burden of Disease Study was the first worldwide comprehensive burden of disease evaluation since the initial 1990 epidemiologic study. Using the disability-adjusted life years (DALY), a metric initially proposed for the 1990 study that captures both premature mortality and the prevalence and severity of illnesses, disease burdens were calculated for 291 causes in 21 regions of the world (including 187 countries) for 1990, 2005, and 2010 to enable identification of significant trends over time.¹⁴ While the global DALYs remained stable from 1990 to 2010, the study identified a significant shift from communicable, maternal, neonatal, and nutritional causes to noncommunicable causes (Fig. 49-6).¹⁵

In the 2006 Disease Control Priorities 2^nd edition, the global burden of premature death and disability from surgically treatable conditions was estimated at 11% of the total global burden of disease.¹⁰ Recently, country-wide population surveys using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) methodology identified a large unmet burden of surgical disease. In Sierra Leone, 25% of deaths of household members during the previous year might have been averted by timely surgical care; 25% of respondents also reported a ­current condition needing surgical attention.¹⁶. In Rwanda, in 2011, the SOSAS survey found 41.2% of the population had at least one operative condition during their life time; 6.4% of the population was found to have a current surgically treatable condition.¹⁷ Using the percentage of the population currently needing surgical care from Rwanda and Sierra Leone combined with the 2012 population in Sub-Saharan Africa of almost 900 million, there are between 56 million and 218 million people just in Sub-­Saharan Africa needing surgical attention today! Untreated acute and chronic surgical conditions represent a ­significant unmet burden of disease that have major impact on the ­economies of these nations.¹⁸

Cancer

Patients and their communities in low- and middle-income countries(LMICs) bear a much greater share of the burden of cancer than high-income countries. The dramatic increase in the proportion of reported cancer cases in LMICs is a result of population growth, aging populations, and the decreased mortality from infectious diseases. In 1970, only 15% of newly reported cancer cases worldwide were from the developing world; by 2008, this proportion rose ­dramatically to 58% and is expected to grow to 70% by 2030.¹⁹ Previously thought to be a disease almost exclusive to high-income countries, nearly two-thirds of the 7.6 million cancer deaths worldwide occur in LMICs. Mortality from cancer correlates inversely with a country’s economy for certain treatable cancers, including breast, testicular, and cervical cancer—LMICs have higher case fatality rates than high-income countries (Fig. 49-7).^19,20

For example, breast cancer case fatality rates illustrate the great disparity in outcomes between regions. Case fatality rates in East Africa reach an unacceptable 59% compared to 19% in the United States.²⁰ In LMICs, patients have very limited access to screening. They present for care with much later stages of cancer. In Haiti, after the great earthquake, in 2010, and after the initial onslaught of orthopedic injuries, many aid organizations found themselves faced with the unmet underlying burden of disease, including late stage breast cancer and other tumors(Fig. 49-8).

Trauma

Trauma has become a leading cause of death and disability around the world; 90% of trauma deaths occur in LMICs.²¹ Approximately 32% more people die as a result from injuries than from malaria, tuberculosis, and HIV/AIDS combined representing 10% of the world’s deaths (Fig. 49-9).^22,23 In the United States, a patient presenting with an injury in a rural community has a higher mortality than those from an urban setting.²⁴ This disparity is much more pronounced in economically disadvantaged societies where seriously injured patients from road traffic accidents are twice as likely to die compared to similarly injured patients in a high-income setting (Fig. 49-10).^22,25 Additionally, death is much more likely to occur in the pre-hospital settings for injured patients from low-income countries. The lack of integrated communication and emergency transportation systems contribute to the pre-hospital risk, while the lack of infrastructure, supplies, and personnel contribute to in-hospital mortality.

Burns

Almost 11 million people worldwide sought medical or surgical care related to burns in 2004. However, the vast majority of burned people never present for medical care. Burns represent a significant cause of death as well as disability globally.²⁶ The vast majority of deaths from fires (95%) occur in LMICs. Burns result in nearly 200,000 deaths each year from fires while other forms of burns, including scalds and electrical burns, represent another significant source of death and disability. Women and children in LMICs are most likely to be burned in domestic kitchens; men are more likely to be burned in the workplace. The economic and social impact from long hospitalizations and from the resulting disfigurement provides a significant negative stigma causing ostracism and rejection.

Of all the forms of trauma worldwide, burns are the only type that predominantly afflicts women and children. Southeast Asia accounts for 27% of the burn-related deaths worldwide; 70% of people dying from burns in the region are women.²⁷ Cooking on wood, charcoal, or low kerosene stoves also puts children at risk, particularly from scalding (Fig. 49-11). Small children in the WHO African region have triple the number of burn deaths as children worldwide. Contrast this with the United States, where more burns and burn deaths affect men.

People living in rural areas suffer disproportionately because there are fewer facilities capable of managing the acute and chronic aspects of burn management and because the population is generally poorer. Surgical grafting and management of contractures is often best done in specialized burn centers, but these are rare in LMICs. Telemedicine has been shown to be effective in managing burns and preventing complications.²⁸

Human Resources

The greatest burden of disease occurs in areas where human resources—physicians, nurses, pharmacists, and other healthcare workers—are scarce (Fig. 49-12).²⁹ The proportion of physicians is low both in high population areas and in areas where the population is growing most rapidly (Fig. 49-13).^30,31 Fully trained surgeons and anesthesiologists comprise only a small proportion of the total number of the Human Resources in Health (HRH). In the Eastern Mediterranean, Southeast Asia, and Africa, HRH per 1000 people falls below the WHO minimum threshold (Fig. 49-14).²⁹ Many countries in Africa—for example Tanzania and Ethiopia—have only 0.6 surgeons per 100,000 population while the United States and Canada have 51 and 26 surgeons per 100,000 population, respectively.³² To provide the same concentration of surgeons in East Africa that currently exists in Canada would require training an estimated additional 42,000 surgeons.³³

Primary care physicians, nurses, midwives, or advanced care practitioners (ACPs) provide much of the basic surgical and anesthetic care in LMICs. Where regulations allow, “task shifting,” or training ACPs to deliver surgery and anesthesia services previously allowed only under the purview of fully trained specialists, can provide expanded access to care.^34,35,36 Non-M.D. practitioners, variously known as assistant medical officers (AMOs) or “tecnicos de cirurgia” in Mozambique, often have extensive operative experience, including obstetrical care and are the primary providers of surgical care in a region.^37,37,38 Task shifting to ACPs also occurs in the United States and other countries where they fill a need otherwise unmet by specialists even in major tertiary care centers.³⁹ However, concerns about the quality of care, lack of adequate supervision, and the effect on prestige and professional development for specialists and ACPs, continue to be topics for debate.⁴⁰

Migration of practitioners to economically and culturally favorable locales is universal and not restricted to low-resource countries.⁴¹ However, the net impact on poor countries is greater. In a 2004 study, more than 23% of U.S. physicians received their medical training from other countries; of these 64% were from low-income countries.⁴² Investments in training greater numbers of doctors in these countries, including surgical specialists, have been only partially successful in meeting the demand in poor countries. Until economic conditions improve or opportunities for professional development increase, and ­incentives enticing migration of health care workers to high-income countries abate, it is unlikely that the most skilled practitioners will remain in resource-poor areas beyond their immediate obligations.^{43,44,45,46,47}

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.

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

International Organizations

United Nations (UN)

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

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)

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

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.

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 3^rd edition. There are three significant developments helping to accelerate the integration of surgery and public health:

1. Improved understanding of the burden of surgical disease and its significant component of the overall burden of global disease;

2. Recognition that surgery has a primary, secondary, and tertiary preventative role; and

3. 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

Trauma Care

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).

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)

Cancer Initiatives

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).

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

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}

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 deliveries^100,101. 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:

1. socioeconomic and cultural

2. accessibility of facilities and

3. quality of care (Fig. 49-26)¹⁰⁴

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)

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

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 Partnerships

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 21^st 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)

Ethics

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

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.

Surgeons of the future will need to educate themselves in areas that have not historically been taught in surgical curricula. Beyond the business of surgical practice, there is a complex ecosystem that supports surgical care. Surgeons must become more aware of the complexities of cost in order to be able to shape the environment in which they work. They must understand better what patients are seeking from the surgical experience rather than focusing primarily on a narrow view of what surgery might have to offer. Surgeons must engage in policy development and advocate for affordable and accessible surgical care without sacrificing quality. Thoughtful technology design can focus on improving quality and on decreasing cost, both in poor and wealthy countries. As our colleagues in public health and the World Bank, Paul Farmer and Jim Kim have challenged us, “We need our surgical colleagues to speak fluently about rebuilding infrastructure, training, personnel, and delivering high-quality care to the very poorest.”⁷