Surgery as a Global Health Issue: General Approach

Antonio Carvajal, MD, SGH.

Chief Executive Officer Carvajal-Klein Foundation

Overview
Global health community has recently recognized that surgical conditions form a significant burden of disease and have cost-effective interventions. A surgical condition is one that requires suture, incision, excision, manipulation, or other invasive procedures that usually require anesthesia.

Surgical interventions play a major role in helping to prevent death and chronic disability.

Population Disease Burden

Surgery is at the end of the spectrum of the classic curative medical model and, as such, has not been routinely considered as part of the traditional public health model. However, no matter how successful prevention strategies are, surgical conditions will always account for a significant portion of a populations disease burden, particularly in developing countries where conservative treatment is not readily available, where the incidence of trauma and obstetrical complications is high, and where there is a huge backlog of untreated surgical diseases. (Debas, H. et al. 2010)

UN Millennium Development Goals

Increasing access to surgery, and improving the quality of surgical interventions, may also help to achieve many of the 2015 United Nations Millennium Development goals.
Reducing child mortality (Goal 4) Improving maternal health (Goal 5) by treating obstetrical complications. Tackling infectious diseases, including HIV through male circumcision. Halving the number of people living in poverty (Goal 1) since surgical conditions often put people out of work.
For example, a survey in Pakistan found that blindness, most commonly due to cataract, was associated with poverty. (PLoS Medicine Editors, 2010)

road traffic accidents, falls, burns, disasters, domestic violence, pregnancy related complications, infections and congenital defects

Surgical Services

Basic Human Rights to Health

Global Burden (Low and Middle Income countries)

Surgical Care, Expensive?

Most organizations preferentially fund programs targeting infectious diseases, despite increasing evidence that charts the vast global burden of surgical conditions and the fact that relatively simple, cost-effective and curative surgical procedures can avert disability and premature death from many life-threatening emergencies and other conditions. (McQueen et al., 2010)

Cost of Surgical Burden

For instance, the estimated cost of surgical DALY (disability adjusted life years) gained at a district hospital in Africa ranges from $19 to $102. In comparison, antiretroviral therapy for HIV infection is estimated to be $350-$1,494 per DALY averted. (Luboga, S. 2009) Existing data suggests that many surgical interventions would decrease burden at low cost.(McQueen et al., 2010)

WHO: Global Initiative for Emergency and Essential Surgical Care

In 2005, the WHO established the GIEESC, which strives to strengthen the capacity to deliver effective emergency surgical care, as well as reduce death and disability from road traffic accidents, trauma, burns, pregnancy related complications and other disasters. In 2007, experts in surgery, anesthesia, health policy and epidemiology came together to form the Bellagio Essential Surgery Group. The group encourages surgeons to participate in advocacy and education and to partner with public health professionals.

Partners in Health PIH

In 1996, Partners in Health helped fund and build an operating room in Haiti, and with the help of Haitian doctors, the organization has developed a surgical care system at their partner hospital, Zanmi Lasante. (PLoS Medicine Editors, 2010)
public health specialists now recognize not only that surgery has a preventive role, but also that surgical treatment provided in low-tech community hospitals is cost-effective. (Debas, H. 2010)

Public health workers have also recognized that access to essential surgery should exist within the right to health.

Conclusion
Surgical care has an essential role in global public health. Not recognizing its protagonism will ensure that the morbidity and mortality endured by millions of people in poor countries unable to access surgical care will continue to remain invisible to the rest of the world.

References
1. 2. 3. Ozgediz, D., Jamison, D., Cherian, M., and McQueen, K. The burden of surgical conditions and access to surgical care in low- and middle-income countries. Bulletin of the World Health Organization. 86.8 (2008): 577-656. Accessed on 1 November 2010. http://www.who.int/bulletin/volumes/86/8/07-050435/en/ PLoS Medicine Editors, A Crucial Role For Surgery in Reaching the UN Millennium Development Goals. PLoS Medicine. 5.8 (2008): 1165-1167. Accessed on 29 October 2010. <ftp://ftp.apop.allenpress.com/EP-inbox/plme-05-08-collect/plme-05-08-15.pdf> Debas, H., Gosselin, R., McCord, C., Thind, A. Surgery. In Disease Control Priorities in Developing Countries. (Washington, D.C.: World Bank, 2006). Accessed on 27 October 2010. <http://www.ncbi.nlm.nih.gov/bookshelf/br.fcgi?book=dcp2&part=A9770 Luboga, S. Increasing Access to Surgical Services in Sub-Saharan Africa: Priorities for National and International Agencies Recommended by the Bellagio Essential Surgery Group. PLoS Med. 6.12 (2009). Accessed on 29 October 2010. <http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2791210/> McQueen et. al. Essential Surgery: Integral to the Right to Health. Health and Human Rights in Practice. 12.1 (2010): 137-152. Accessed on 13 September 2010. <http://www.ghdonline.org/uploads/McQueen2010EssentialSurgeryHRto.pdf>

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