Surgery for All: Social Justice for All - Article in UN Special Magazine

7 May 2019 - The Global Surgery Foundation (GSF) published an article in the United Nations Special Magazine. The article can be read below, or by clicking here.

Surgery for All: Social Justice for All

The WHO, UNITAR and the Harvard Medical School Program in Global Surgery and Social Change are developing a new platform to help build capacity in Global Surgery.

A Story from the Field

Late one night, a 29-year-old mother of two was carried into the emergency department of our hospital by her family members. At that point, the group had already travelled for two days from another, more remote hospital in the Himalayan foothills where she had spent the past two weeks. They had tried their best to access a surgeon there but to no avail until arriving at our hospital. The emergency physician on duty quickly diagnosed a perforated peptic ulcer. We were shocked to learn that the X-ray that confirmed her diagnosis, had already been taken 3 weeks earlier. Over the following three days, our surgical team worked overtime to make up for the severity of her late presentation. Despite having surgery, blood transfusions and all the necessary antibiotics, she did not improve and finally passed away.

Unfortunately, outcomes like this are far too common. Patients present late because they are unable to access a functional, safe surgical service. Thankfully, and more commonly, our surgical department saw better outcomes and witnessed the significant impact they had on the community that they serviced. Shortly after the case of the 29 year-old mother, a man from the next valley, who came with his wife and three children, presented with a complete bowel obstruction that had been ongoing for five days. During his surgery, we found dead bowel that was near perforation. The obstruction was due to a massive infestation of round worms. Following a routine bowel resection, he went home six days later in good condition and with worm medicine for the whole family. His outcome would have been the same as the other patient if surgery had not been available in a timely manner.

The sad reality is that stories such as these are all too common in low and middle-income countries (LMIC). However, these same stories can help bring the important human element to the dialogue as world leaders look for solutions on how to provide appropriate surgical care globally along with Universal Health Coverage (UHC). Indeed, the personal stories illustrating the frontline realities are an important reminder as to why the world needs to persevere in its efforts to achieve the UN Sustainable Development Goals (SDGs) and the 2030 Agenda. The most vulnerable and impoverished of our world still face tremendous challenges accessing good health care, which is one of the most important factors in improving their life and avoiding poverty. There is increasing evidence to show that without a significant increase in the availability of safe and affordable surgical care, the world will be hard pressed to achieve UHC and many of the SDGs.

The Numbers

The global burden of non-communicable diseases (NCDs) and traumatic injury is increasing at an alarming rate and completely eclipsing communicable diseases. Recent data shows that almost 30% of the world’s total burden of disease is caused by conditions that require surgical, obstetric or anaesthesia expertise and training. Worldwide, roughly 5 billion people do not have access to safe, affordable and timely surgical care. More shockingly, approximately 90% of people living under the poverty line do not have access to surgery. As a result, a staggering 17 million people dying each year from surgically preventable causes, the greatest of these in the most vulnerable countries. This reality makes it imperative for the world’s leaders focus more attention on the tremendous need to build up surgical care in the countries that need it most.

Figure 1: The scale of the challenge

It is also well recognized that if the world does not address the enormous needs in surgical care, this inaction will cost LMICs approximately US$12 trillion in lost outputs (total GDP losses). When countries invest in surgical capacity, they are also investing in the economic development of their country. Furthermore, as countries build up surgical services, there is a concurrent rise in the overall capacity of that health system since surgical care (surgery, obstetrics and anaesthesia) has an impact across all sectors of health care.

Looking Back

In 1980 at the World Congress of the International College of Surgeons in Mexico City, Dr. Halfdan Mahler, the Director General of the WHO at the time, gave a profound and prophetic address. He outlined the importance of surgery in achieving the main health target set at the 1977 World Health Assembly (WHA) of “Health for All by 2020”. He clearly stated that “Social injustice is socially unjust in any field of endeavour, and the world will not tolerate it for much longer. So the distribution of surgical resources in countries and throughout the world must come under scrutiny in the same way as any other intellectual, scientific, technical, social or economic commodity. The era of only the best for the few and nothing for the many is drawing to a close.” (1)

Almost four decades later, we are still grappling with the same challenges, albeit with an increasingly complex, changing and inter-related global environment. Over the last several decades, the world has met many of the health challenges of the time with vigour and resolute determination to overcome the seemingly insurmountable problems. The greatest example of this is seen with the success in dealing with HIV, TB and Malaria. Many lessons can be learned from that experience. As we face the new challenges of a quickly changing disease burden profile, it is important for the world health policy leaders to rapidly adapt to find new solutions to meet the changing needs. This is especially true as we see the quickly increasing need for strong surgical capacity around the world, and especially in LMICs. The simple truth is that without increasing access to safe and affordable surgical care, the world will be hard pressed to achieve UHC or many of the SDGs.

In 2008, Drs. Paul Farmer and Jim Y Kim coined the term describing surgery as the “neglected stepchild of global health”. In their landmark paper, they outlined the reality for surgical care globally and offered suggestions for moving this important agenda forward, including the importance of UHC (2). In the years following that, momentum continued to build as more surgeons and public health specialists realized the importance of surgery in meeting the global health needs. Two watershed events occurred in 2015 with the unanimous passage of WHA 68/15 on strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage and the Lancet Commission on Global Surgery with its findings and recommendations. Both set the stage to what has now grown into an increasing global awareness of the great need for surgical care to be addressed in order to achieve the SDGs. Indeed, 9 of the 13 targets of SDG3 are directly or indirectly related to surgical care and will only be achieved with improved surgical, obstetric and anaesthesia care service delivery.

The Way Forward

With this new realization, many countries are making efforts to incorporate robust national surgical, obstetric and anaesthesia plans (NSOAP) into their national strategic health plans. Indeed, five countries have completed their NSOAPs, with 11 others well along in the process. In March 2019, the Harvard Medical School Program in Global Surgery and Social Change and the WHO Emergency and Essential Surgical Care Programme hosted a regional meeting in Dubai3 for governments, academics and funding agencies to further explore how to expand the NSOAP process. There was excellent representation from Africa, Asia and the South Pacific, including delegates from the World Bank and other significant stakeholders. The general consensus of the conference participants was that the time was long overdue for the world leaders and health policy makers to act in response to the challenges spoken years ago by Drs. Mahler, Farmer and Kim. This sentiment was well summarized in the special address to the conference by Dr. Tedros Adhanom Ghebreyesus, Director General of the WHO, when he said, "No country can achieve Universal Health Coverage unless its people have access to safe, timely, and affordable surgical services...It's therefore vital that countries invest in surgery." 4 This message echoes that of the Lancet Commission on Global Surgery which stated that “the delivery of surgical services and essential procedures must be embedded within the targets for the SDGs and UHC.”

In summary, the message is clear: Universal Health Coverage, and indeed most of the targets of SDG 3, are not attainable without increasing the global surgical capacity. The target date for the SDG agenda is only 11 years away. Time is short. There is an urgent need for the world leaders to join the efforts and make this a global priority. The building enthusiasm and resolve from surgeons, government policy makers, academics, and more recently funders to meet these needs has started the process. Let us reach for this goal together.

1) https://www.who.int/surgery/strategies/Mahler1980speech.pdf?ua=1
2) https://link.springer.com/article/10.1007%2Fs00268-008-9525-9
3) https://www.pgssc.org/2019-national-surgical-planning
4) https://www.youtube.com/watch?v=P1XLthxQs7g