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Global Surgery: The Past, Present and Future

Earlier in 2021 a global surgery essay competition was organised collaboratively by ARU Surgical Society and ARU Friends of Médicins Sans Frontières, alongside their Global Surgery Symposium, which took place on the 1st of May 2021.


We are proud to publish one of the prize essays.


By:

Tamanna Agarwal

tamanna4agarwal@gmail.com


 


Global Surgery: The Past, Present and Future


The hushed operating theatre, a surgeon in scrubs with a scalpel, sterile fields and decisions that dictate life and death. Surgery takes up a large space in our collective imagination of medicine. But global surgery, the neglected stepchild of global healthcare, is poorly understood even by those practicing it.


Surgery is multifaceted, requiring more than a surgeon and an operating room. It requires anaesthesia, nursing care, functional equipment, and equitable financing mechanisms thus investing in it strengthens the entire healthcare system (1,2). Global surgery is an enterprise that intends on providing equitable surgical care to the world’s population, based on the tenets of access, need and quality (1) (Fig. 1). A robust surgical system is scalable, and its resources can be repurposed in times of crisis or need.



Fig. 1 The multifaceted global surgery. As presented in Bath et. al (1)


A study in 22 Lower- and Middle-Income Countries (LMICs) found that over a third of facilities had no access to oxygen nor anaesthetic machines (3). Basic technology like pulse oximeters can save lives in a pandemic but are missing in almost 70% of operating rooms in Eastern sub-Saharan Africa (2). Building strong surgical infrastructure is a preventative public health measure.


Literature shows the initial belief of the global burden of disease treated by surgery estimated to be 11% is inaccurate, with experts suggesting a 30% burden instead (7). This is felt acutely in LMICs. Out of the 234 million major surgical operations performed annually worldwide, the poorest third of the world’s population receives 3.5% of these (3).


India, Africa, and Latin America make up 42% of the world population but represent only 7.9% of researchers (2). Research from LMICs represents 4% of all literature (1). How is one to practice evidence-based, data-driven medicine in an absence of data?


Lack of data stems from LMICs surgeon’s inability to participate in the time and money intensive process of getting published (2). Higher-Income Countries (HICs) surgeons on surgical camps or charitable missions work with LMICs surgeons but often do not give them due credit (4). LMICs should be treated as partners and their research and clinical work be given priority. Data must fill gaps in knowledge, drive national resource and fund allocation (2). Further, data and need-based donations will allow clean and unused medical supplies to go to the right place, reducing waste and being cost effective. Philanthropy, however, cannot substitute policy.

There is much to learn from LMICs for low-cost, sustainable solutions. The best example is the use of sterilised mosquito netting as a hernia mesh with results showing no significant difference in clinical outcomes (3). These simple, effective adaptations of existing inventions often lack scientific documentation, making it difficult for dissemination beyond their country of origin (6). This emphasises the need for supporting LMICs-centric research that provide contextual protocols that represent their availability of resources, instead of blindly following HICs standards that they cannot fulfil (13).


While using learnings from LMICs, are we doing justice to the people in the stories? To reckon with a history of erasure and insufficient representation ethical storytelling is a must. We must find better, less voyeuristic ways of storytelling that are through lenses of healing and empowerment.


‘Surgathons’- surgery hackathons- foster innovation and optimise a local community’s existing resources to solve a problem. Over time this builds a local surgical innovation ecosystem within a sustainable and ethical model. Surgathons empower local stakeholders and provide them with opportunities to provide solutions to local and global surgical problems (11).


Misconceptions regarding the cost of surgery should be addressed. Verguet et al estimate that the scaling up of surgical services in LMICs at an annual rate of 8.9% in the number of surgeries performed between 2012 and 2030 would cost USD420 billion, compared to USD12.3trillion in economic productivity losses due to untreated surgical conditions (12, 13).(Fig. 2). This cost represents 1-8% of the current annual health spending in LMICs and can be funded domestically.



Fig. 2 Annual and cumulative GDP lost in low-income and middle-income countries from five categories of surgical conditions (2010, USD, purchasing power parity). Data are based on WHO’s Projecting the Economic Cost of Ill-Health (EPIC) model. GDP= gross domestic product. As presented in Meara et al.(13)


Investors in global health initiatives prefer disease-specific initiatives over horizontal causes such as surgery (5). Surgery’s non-communicable nature is the cause of its lack of public support. Understanding is critical to action and benefits must be elucidated to public and policymakers.


Advocacy must extend to within the medical community to educate surgeons on the tenets of global surgery, and the way it plays into healthcare as a cornerstone of infrastructure, investment, and capacity to expand in times of need.


Basic surgical interventions in trauma and emergency obstetric care, cataracts, hernia and cleft lip and palate cost less than 200USD/DALY (disability-adjusted living year) averted (8). The notion that surgery is a luxury or unaffordable is a barrier to timely treatment, allowing injuries to worsen. Better access allows ailments to be looked at earlier, necessitating lesser magnitude of surgery, improving outcomes, reducing postoperative time in the hospital, and reducing chances of postoperative infection (9). Catching surgical diseases early in the disease progression is cheaper.

Cross subsidisation is an effective tool used in LMICs where richer patients who can pay higher fees for a procedure help subsidise the same procedure for poorer patients (3). This allows one facility to cater to patients from all socioeconomic backgrounds, without finance being a limiting factor.


Beyond improving surgical outcomes, improving access to bellwether hospitals enhances a patient’s quality of life. Improving connectivity between primary and secondary care centres involves investing in public transport and better roads. This further reduces the disease burden of injury by providing safe means of transport. Conversely, travel costs can be eliminated by investing in local health centres.

There is an overwhelming need for sustainable practices in surgery. Rizan et al eloquently interlink planetary and human health. While individuals are making more sustainable life choices, medicine remains a large emitter of greenhouse gases. The NHS is responsible for a quarter of national public sector greenhouse gas emissions. A single operation generates ridiculous amounts of CO2 equivalents (Fig 3). Where possible, single-use items should be switched to reusable; this increases the life cycle of an item and reduces the supply-chain carbon footprint.



Fig 3. The equivalence between the carbon footprint of a single operation and driving an average petrol car. As presented in Rizan et al.(10)


Another point of importance is the labour rights associated with production of surgical equipment, in countries like Pakistan, Malaysia and Mexico (10). Working in abysmal conditions, should producing surgical equipment for one sentence the other to a lifetime of disability? This increases the disease burden on a LMIC country, perpetuating a vicious cycle of disease and poverty.



Fig 4. The case for global surgery made in the past decade. Adapted from Shawar et al (5)


As the world we live in grapples with health and wealth inequity, global surgery must be imagined as a long-term relationship between countries with extensive benefits (Fig. 4). Historically, HICs have benefited from modern medical practices and their surgeons have practiced and perfected their techniques on disadvantaged communities in LMICs. Surgical colonialism must end, and it is the responsibility of institutions and states in HICs to assist LMICs in reaching equitable indicators of global surgery.


 

References

1. Bath M, Bashford T, Fitzgerald JE. What is 'global surgery'? Defining the multidisciplinary interface between surgery, anaesthesia and public health. BMJ Glob Health. 2019 Oct 30;4(5):e001808. doi: 10.1136/bmjgh-2019-001808.

2. Ng-Kamstra JS, Greenberg SLM, Abdullah F, Amado V, Anderson GA, Cossa M, Costas-Chavarri A, Davies J, Debas HT, Dyer GSM, Erdene S, Farmer PE, Gaumnitz A, Hagander L, Haider A, Leather AJM, Lin Y, Marten R, Marvin JT, McClain CD, Meara JG, Meheš M, Mock C, Mukhopadhyay S, Orgoi S, Prestero T, Price RR, Raykar NP, Riesel JN, Riviello R, Rudy SM, Saluja S, Sullivan R, Tarpley JL, Taylor RH, Telemaque LF, Toma G, Varghese A, Walker M, Yamey G, Shrime MG. Global Surgery 2030: a roadmap for high income country actors. BMJ Glob Health. 2016 Apr 6;1(1):e000011. doi: 10.1136/bmjgh-2015-000011.

3. Ologunde R, Maruthappu M, Shanmugarajah K, Shalhoub J. Surgical care in low and middle income countries: burden and barriers. Int J Surg. 2014;12(8):858-63. doi:

10.1016/j.ijsu.2014.07.009. Epub 2014 Jul 12.

4. Shrime MG, Sleemi A, Ravilla TD. Charitable platforms in global surgery: a systematic review of their effectiveness, cost-effectiveness, sustainability, and role training. World J Surg. 2015 Jan;39(1):10-20. doi: 10.1007/s00268-014-2516-0. PMID: 24682278; PMCID: PMC4179995.

Page | 4

5. Shawar YR, Shiffman J, Spiegel DA. Generation of political priority for global surgery: a qualitative policy analysis. The Lancet Global Health. 2015 Aug; 3(8):e487-495. doi: 10.1016/S2214- 109X(15)00098-4

6. Ma, X., Thomas, H., & Kanmounye, U. (2020). Beyond technology: review of systemic innovation stories in global surgery. Journal Of Public Health And Emergency, 4. doi:10.21037/jphe 2020-gs-06

7. Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health. 2015 Apr 27;3 Suppl 2:S8-9. doi: 10.1016/S2214- 109X(14)70384-5.

8. Horton S, Gelband H, Jamison D, Levin C, Nugent R, Watkins D. Ranking 93 health interventions for low- and middle-income countries by cost-effectiveness. PLoS One. 2017 Aug 10;12(8):e0182951. doi: 10.1371/journal.pone.0182951.

9. Fu SJ, George EL, Maggio PM, Hawn M, Nazerali R. The consequences of delaying elective surgery: surgical perspective. Ann Surg 2020 Aug; 272(2)e79-80 doi:

10.1097/SLA.0000000000003998

10. Rizan C, Reed M, Mortimer F, Jones A, Stancliffe R, Bhutta MF. Using surgical sustainability principles to improve planetary health and optimise surgical services following the COVID-19 pandemic. BMJ Bulletin. 2020 Jul; 102(5)e177-181 doi: 10.1308/rcsbull.2020.148

11. Mitra S, Ashby J, Muhumuza A, Ndayishimiye I, Wasserman I, Santhirapala V, Peters A, Vervoort D, Jacob O, Gnanaraj J, Natarajan PG, Afshar S. Surgathon: A new model for creating a surgical innovation ecosystem in low-resource settings. BMJ Global Health. 2020 Feb 5(2) e002162. doi:10.1136/bmjgh-2019-002162.

12. Verguet S Alkire BC Bickler SW et al.Timing and cost of scaling up surgical services in low income and middle-income countries from 2012 to 2030: a modelling study. Lancet Glob Health. 2015; 3: S28-S37

13. Meara JG, Leather AJ, Hagander L, Alkire BC, Alonso N, Ameh EA, Bickler SW, Conteh L, Dare AJ, Davies J, Mérisier ED, El-Halabi S, Farmer PE, Gawande A, Gillies R, Greenberg SL, Grimes CE, Gruen RL, Ismail EA, Kamara TB, Lavy C, Lundeg G, Mkandawire NC, Raykar NP, Riesel JN, Rodas E, Rose J, Roy N, Shrime MG, Sullivan R, Verguet S, Watters D, Weiser TG, Wilson IH, Yamey G, Yip W. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth. 2016 Feb;25: 75-8. doi: 10.1016/j.ijoa.2015.09.006.


 

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