NexThought Monday – ‘The Neglected Stepchild of Global Health’: About 5 billion people have no access to basic surgical care
A global effort is under way to help surgery shed its designation as “the neglected stepchild of global health.” With the incidence of surgically treatable conditions on the rise in emerging economies, and a recently released report on the unaddressed surgical burden from the Lancet, the lack of access to surgery around the world is finally getting attention.
Considering the fact that approximately 5 billion people have no access to basic surgical care, now is the time to make surgery a global health priority. Every day, victims of accidents, those who suffer from chronic disease and women experiencing childbirth complications are dying from conditions that can be addressed with the simple, low-cost surgical procedures that are taken for granted in wealthy countries.
Historically, this massive gap in global health has been temporarily and often inadequately filled by teams of foreign surgeons traveling to under-resourced settings for short periods of time, bringing with them the skills, equipment and other resources necessary. This model does not address the fundamental reason for the lack of surgical care worldwide: The underlying infrastructure that is needed to make surgical care safe, affordable and accessible is currently unattainable in low-resource settings.
In Uganda, we had the privilege of meeting a few local surgeons who have committed their lives to providing much-needed surgical care in whatever way possible. At Holy Family Virika Hospital, Dr. Priscilla Busingye tries to reach all of the women of Kabarole District with a donated van that can transport patients who otherwise would never be able to see the inside of a hospital. Yet, as Kabarole’s only obstetrician, Dr. Busingye knows there are many women in need of emergency obstetric surgery or fistula repair who she still cannot reach.
Dr. Ian Clarke, another physician who has practiced in remote regions of Uganda for decades, has performed many Caesarean sections using ether for anesthesia and instruments disinfected in boiling water – techniques that were superseded by basic technological developments in the 19th century. Considering the limitations these surgeons face, the work they do is truly heroic and invaluable to the communities they serve. But they know that with basic, reliable infrastructure, they could do so much more.
Instead of transplanting surgeons and other resources from high-resource settings to those that are lacking, global health efforts must focus on building in-country capacity to support their own essential infrastructure. Now that the massive scope of the global surgery problem has been revealed, it is time to make death or disability from common, treatable conditions obsolete in sub-Saharan Africa – just as it is in the United States – with real, sustainable solutions.
To achieve this goal, we must develop a consensus about the fundamental infrastructure that surgical care requires, and understand the obstacles to its availability. Any safe surgical procedure, no matter how basic, is dependent upon three basic components: trained personnel, reliable anesthesia delivery and sterile instruments. The obstacles to making these components available for every health care system can seem daunting. Reliable access to electricity is simply unheard of in many regions, and numbers of physicians, let alone certified surgeons, are woefully inadequate. Poor electrification and physician shortages may be the reality, but this is no excuse for the death of millions of women as they bring life into the world. Nor is it excusable to deny basic care to 5 billion people, especially when solutions can be developed to work within even the most crippling resource limitations.
We can begin by promoting investment and innovation in solutions that recognize and reflect resource realities in places where surgical care is unavailable. Just because surgery in wealthy nations depends on large amounts of electricity to run automated sterilizers and complex anesthesia machines, and surgeons with years of school and piles of debt behind them, does not mean it is the only way.
We will be collaborating on several articles for NextBillion with friends who are working on the ground to carve a new pathway to essential surgery, including a distinguished surgeon and anesthesiologist who are committed to making surgical care a reality, refusing to allow a lack of electricity or certified surgeons to stand in their way. The articles will focus on the three components of surgery – sterilization, anesthesia and workforce – and will describe the work that is being done to make them a reality for any setting. They will introduce innovations in surgical technology and practice: a sterilization system that uses nitrogen dioxide gas to sterilize without electricity; machines that make anesthesia delivery and monitoring possible without electricity; task-shifting and remote training programs for local health workers.
These innovations are the pathway to global surgery, but they will never realize their potential if the global health community does not work together to rapidly scale them to meet the massive need. Our hope is that these articles will give a voice to the pioneers of global surgery and help to coalesce a movement around the promotion of the solutions that will help these pioneers achieve their goals. Five billion people around the world are waiting.