Global Surgery: A Forgotten Piece of the Health Puzzle
By Hugh Shirley, Biochemistry, 2019
This piece was originally published as part of our Summer 2019 series.
Surgery isn’t a topic that comes up very often in a public health lecture. In the world of health prevention and promotion, pills and vaccines are often at center stage. If you listen to the conversations in a global or public health classroom, you’ll hear about reducing child mortality rates with malaria drugs or about the burden of neglected tropical diseases in low- and middle-income countries (LMICs) around the world. Those issues are vital for health and necessary for a student to understand what work is being done by organizations and governments right now. What’s often missing in those conversations, however, is a mention of surgery.
Surgical care is a necessary part of a complete health package. Without access to surgery, you lose access to Caesarian sections or cataract removal. You lose the ability to repair an open fracture or to fix a cleft lip. This all might seem obvious; of course you need surgeons to improve health. I’d argue that it’s just as obvious that you need medicine to prevent malaria or HIV. But being obvious doesn’t get you on the agenda. If you don’t include a key aspect of human healthcare in the conversation, then pieces get lost, systems breakdown, and the whole thing crumbles.
Surgical care is a necessary part of a complete health package.
I’ll illustrate this with some numbers, but first we need to understand some global health jargon. The burden of disease is a catchall used to describe the collective human productivity lost because of specific diseases or disease categories, such as noncommunicable diseases or injuries. Often, this might be measured as a disability adjusted life year (DALY), which tries to capture the average years of life lost because of disease. Each year, over 77.2 million DALYs can be attributed to causes that are treatable with surgical care. Essentially, 77.2 million years of human life are lost around the world annually because people can’t access the surgical care they need. Perhaps a more relatable figure is that in 2010, 32.9 percent of all deaths worldwide were caused by conditions that required surgical intervention.
How could a third of all deaths be caused by things that need surgery? There are some obvious candidates, such as cancer or heart disease, but what’s surprising is that so many of these deaths are occurring in those LMICs that you might associate with cholera or HIV. The greatest burden of surgical need lies with those same communities. In fact, only around six percent of all surgical procedures worldwide are undergone by the poorest third of the world’s population. While cancer and heart disease aren’t at the top of the list for surgically treatable conditions behind that 32.9 percent of all deaths figure, they do factor into the equation. But it’s more than just what disease is causing the greatest loss of life — it’s a matter of priorities, infrastructure, access, and money.
Only around six percent of all surgical procedures worldwide are undergone by the poorest third of the world’s population.
In Baringo County, Kenya, there are two major operating theatres serving a population of over 700,000 spread over an area around four times the size of Rhode Island. The city of Boston has an estimated population of just under 700,000. The number of operating theatres in Boston is staggering, Massachusetts General Hospital alone has at least 35. There are approximately 6 specialized surgeons in Baringo County. You couldn’t get on the T without bumping into a member of Boston’s surgical cadre. It might be a stretch to compare rural Kenya to one of the foremost medical centers of the world, but it does go to show that the conditions needing surgery aren’t absent in rural Kenya, but the people and places needed to perform those surgeries are.
When you don’t have an operating theatre available to perform a necessary surgical procedure, what happens? You must prioritize. Say a patient with a hernia in Baringo County is scheduled for surgery one day. The surgeon is ready, the theatre is prepped, the patient is waiting. An ambulance races up to the hospital and drops off a woman in prolonged labor. She’s been referred to the only hospital in the region that can perform a C-section. In an emergency situation, where the mother and baby’s lives are immediately on the line, the C-section will take priority over the hernia repair. The man with the hernia will just have to wait because there’s not another available operating theatre, or surgeon for that matter, where he can get his elective surgery. This is a common occurrence across LMICs where the infrastructure doesn’t exist to support the surgical needs of the community and is one of the primary drivers for the high burden of surgically preventable deaths in LMICs.
Priorities and infrastructure interact with the next two factors that result in poor health outcomes for the world’s surgery patients. Access refers to a patient’s knowledge about their health, their ability to reach the existing infrastructure, and their ability to navigate the health system. Money refers to not only the patient’s ability to pay for their care, but to pay for all of the more general factors surrounding their access to surgery.
Two hours is the standard global health leaders are pushing to achieve for surgical access worldwide.
If you look back at Baringo County, you’ll find a population with poor health-seeking behavior. For example, snake bites are common in the region, but people will often delay seeking treatment for hours or even days. That delay can turn a simple procedure like stitches into a much more complicated one like an amputation. When a patient finally does seek care, they need to get to a health facility that can handle their case, ideally within two hours. In Baringo, roads are poor or nonexistent. Motorbike taxis, called boda-bodas, or crowded buses, called matatus, are often the only means of transit. It can take over two hours to reach a health facility of any kind, let alone the one facility in the county that can handle the increasingly complicated snake bite case.
Two hours is the standard global health leaders are pushing to achieve for surgical access worldwide. In 2015, five billion people lived over two hours away from an operating theatre that could perform the three bellwether procedures. The bellwether procedures: C-section, laparotomy, and open fracture repair, signal that a hospital will be capable of performing the majority of procedures that a population base will require.
Without a sufficient national healthcare plan, the cost of surgery can be prohibitive for people with low incomes.
With all the talk of personnel and infrastructure, the cost of these expensive surgeries seems like an insurmountable barrier for many people in LMICs. Without a sufficient national healthcare plan, the cost of surgery can be prohibitive for people with low incomes. Clinics that are supposed to be free often run out of the supplies and drugs they need, and then patients are required to bring their own for the clinicians to use. The cost of transportation to a health facility for a check-up or a referral can limit access to care. Including surgery in the health conversation, through a national surgery, anesthesia, and obstetrics plan (NSOAP), is a step towards building the necessary health systems in many LMICs.
There’s been a significant push for surgery to be a part of the global health conversation in recent years. The 2015 Lancet Commission on Global Surgery compiled a significant amount of research and demonstrated how surgery is an economical, social, and moral imperative for achieving equal health for all people. As more global health policy makers, providers, and activists include surgery in their agendas, we might see a change in the face of global health from one of medicine and vaccinations to a more all-encompassing look.
