Vexing progress towards surgical equity

Written on 16 February 2018

Author: Tom Weiser

Walking through the dark, overcrowded hall between the surgical wards, our team passed an old farmer lying on a thin mattress atop a rusty metal bed frame. He had been struck by a car about four days prior and had a very complex leg fracture. He was flanked by family members; the driver who had struck him crouched by the foot of his bed, ashen-faced, his eyes darting. As the driver, he was responsible for the hospital costs.

The fracture would have been difficult to manage at the best hospital – and here in rural Ethiopia, with little specialised fixation equipment, it was going to be exceedingly problematic.

The patient, the driver, and both families paid a heavy price for such an accident, and they are on my mind as I prepare to lead a discussion on surgical equity at the Challenges of Our Era summit next month. As a practicing surgeon, active researcher, and trustee of Lifebox Foundation, I will make an argument that the global surgical and anesthetic community has made a thousand times: that safe, affordable surgical care and capacity is essential to a functioning health system.

Any room full of public health experts will quickly confirm the significance of road traffic injuries as a public health priority. Likewise, the importance of maternal and child health, HIV, TB, and malaria. And cancer. And hypertension, cardiovascular disease, diabetes and mental health.

Advances of the 20th century

These problems are vexing, yet the public health community has demonstrated remarkable success in addressing many of the major issues that confronted them in the 20th century. With the discovery of penicillin, infectious diseases started to be controllable. The development of successful vaccines dramatically reduced the devastation wrought by common, but devastating viruses. Smallpox was eradicated. Polio has been reduced to a handful of cases a year in the remotest of settings.

Surgery in Ethiopia. Credit: Lifebox

Maternal and child health gains occurred when the public health community started enumerating deaths, defining solutions for improving outcomes, and devoting human and financial resources towards scaled interventions. HIV was and continues to be the focus of herculean efforts, such that vaccines are routinely trialed, anti-retrovirals are available worldwide, and infection has moved from a death sentence to a chronic condition with the expectation of a vigorous, productive life.

These advances were made possible for two reasons. First, the problems were recognised and enumerated with strong epidemiological fieldwork. Second, the world’s public health and funding agencies took notice and came forward with resources to identify and implement solutions. Surgery was failing on both these fronts, but the epidemiological picture is now starting to take shape. It’s not pretty.

Because if that room is full of public health experts from a high Human Development Index country, they can expect to undergo seven operations during their lifetime. Nearly everyone will know a family member or friend who went under the knife. If you ask them about surgery as a public health issue, however, they will likely stare blankly or wave you away as being uninformed or naïve.

Why is improving surgery worldwide so important?

Yet worldwide over 300 million operations occur every year, with death rates as high as 30% in the poorest countries. Surgically treatable diseases are responsible for 30% of the global burden of disease, and kill more people than HIV, TB, and malaria combined.

Surgery is an integral part of any reasonably functioning health system and is an indispensable component of emergency obstetric care (e.g. caesarean delivery), essential to trauma care to reduce or prevent disability and death (e.g. open fracture reduction and fixation), fundamental for diagnosing and treating a range of cancers (most solid tumours require tissue for diagnosis and resection for cure or palliation).

Surgery is critical to preventing deaths from common, but lethal, infections such as appendicitis, cholecystitis, osteomyelitis, and typhoid and peptic ulcer perforation. Disabilities due to cataracts, hernias, obstetric fistulae, wounds, burns, and congenital anomalies all require surgical care and expertise.

A surgery “moon shot”

The epidemiological transition is here, and diseases of pestilence and infection are giving way to diseases of aging and industrialisation. For a developing health system to be prepared for the afflictions of the 21st century, surgical and anaesthetic services are obligatory. Surgery supports diagnosis, treatment, and palliation for a huge range of conditions, even ones not typically considered “surgical” in nature (circumcision helps reduce HIV transmission, for example).

It is true that the requirements of surgery and anaesthesia make demands of a healthcare system: that procurement processes, management, standard procedures, and clinical activities be organised and supported; that standards be jointly established and observed; that equipment be fit for purpose and appropriately serviced and repaired; and that patients have confidence in the safety and quality of the care they receive. This will require tremendous investments: to scale surgical and anaesthetic care to the poorest countries will require investments of up to US$420 billion over the next 20 years.

But there are huge rewards: at current levels of disease burden and disability, low and middle-income countries will lose US$12.3 trillion dollars in productivity over the next 15 years alone. Such losses profoundly impact national income and are projected to reduce annual GDP by up to 2% due to maternal and neonatal conditions, injuries, digestive diseases, and cancers treatable by surgery.

Solving this issue requires a health system “moon shot,” and the commitment, teamwork, investment and innovation that comes with global ambition and change. But public health systems have done this before, and the rewards enrich us all.

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Tom Weiser is an Associate Professor of Surgery at Stanford University, a visiting prof at the University of Edinburgh in the Dept of Clinical Surgery at the Royal Infirmary of Edinburgh, and and a trustee of Lifebox, the global safe surgery nonprofit partnering with Nesta on the Surgical Equity Prize.

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