Global Surgery: An indivisible, indispensable part of health care

Global surgery is an area of study, research, practice, and advocacy that seeks to improve health outcomes and achieve health equity for all people who require surgical care, with a special emphasis on underserved populations and populations in crisis. It uses collaborative, cross-sectoral, and transnational approaches and is a synthesis of population-based strategies with individual surgical care (Dare et al., Lancet 2014).

In today’s information age, an abundance of technology, data, and innovation has enabled more global interconnectedness than ever before. This has allowed for a better understanding of the health inequities that exist in the world. This is not limited to low resource settings as they exist in divisions of high-income countries like the United States and United Kingdom. The vision and mission of achieving health equity for all is the ethos of Global Health. However, until recently, surgery was largely omitted from that equation. The field of Global Surgery has recently gained attention for its efforts to meet the global need for surgical care.

Why Global Surgery?
Global health has historically focused on mitigating infectious diseases such as HIV/AIDS, malaria and tuberculosis, while surgery remained largely absent from the global health agenda. Traditionally, it was believed that incorporating surgery into

Figure 1: Proportion of the population without access to safe, affordable surgery and anesthesia by Institute for Health Metrics and Evaluation region. Image taken from the Lancet Commission on Global Surgery. Image from Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development.

global health would be too expensive, complex, and unsustainable, and moreover, that the global surgical demand was low. However, the burden of diseases that require surgical treatment outnumber HIV/AIDS, malaria and tuberculosis combined. The 2015 Lancet Commission on Global Surgery concluded 5 billion people worldwide do not have access to safe, affordable surgical and anesthesia care when needed (Figure 1). Surgical conditions account for 30% of disability-adjusted life years lost (DALYs), a measure of overall disease burden, expressed as the number of years lost due to ill-health, disability or early death (Shrime et al., Lancet Global Health 2015). Leading conditions requiring surgery include pregnancy, traumatic injuries, and digestive diseases. In low-income and lower-middle-income countries (LMICs) 90% of people cannot access basic surgical care. This amounts to 143 million surgical procedures that go unmet in LMICs each year. Despite this health disparity, the United Nations Millennium Development Goals for improved health by 2015 failed to incorporate surgery in their health plan, and today, the majority of global health funding goes toward infectious disease efforts. With the 2015 Lancet Commission, Dr. Jim Yong Kim, President of the World Bank, called for a “shared vision and strategy for global equity in essential surgical care,” and firmly stated that “surgery is an indivisible, indispensable part of health care.”

Is Global Surgery Feasible?
The Lancet Commission established a target for countries to be able to deliver 5000 operations per 100,000 population by the year 2030, and denoted the workforce density of surgeons, anesthesiologists and obstetricians (SAOs) should be at or above 20 per 100,000 population (Figure 2). For example, according to the World Bank data in 2016, Rwanda had 0.75 SAOs per 100,000 population, compared to 54.7/100,000 in the United States. The estimated cost of increasing surgical care in LMICs by this target is $420 billion. However, the alternative would continue to drive losses in economic productivity, costing $12.3 trillion. Therefore, investing in surgical services in LMICs is both a financially and morally sound investment to save thousands of lives.

Figure 2: Specialist surgical workforce density and maternal survival. A surgical workforce density of more than 20 per 100 000 specialist surgeons, anaesthesiologists, and obstetricians is a goal put forth by the Lancet for 2030.Image from Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development.

What Types of Projects are Ongoing?
At present, numerous multidisciplinary efforts are ongoing. Zambia and Ethiopia were the first to take on the challenge of creating a National Surgical Plans to meet Commission goals. Others are working hard to describe the current state of surgery in various regions by collecting information on the World Bank World Development Indicators, WHO Global Reference List of 100 Core Health Indicators, and the United Nations Sustainable Development Goals. Multiple partnerships are being developed between high-income countries and LMICs to team together for research, training, and health systems strengthening (e.g. Human Resources for Health in Rwanda, King’s Global Health Partnerships in Sierra Leone, Somaliland and Democratic Republic of the Congo). Start up companies like LifeBox are working to ensure safer surgery through pulse-oximeters. No matter your specialty, there is a place in global surgery for you.

How Can I get Involved?
There are many ways to get involved! Here are a few ideas to get you started:

• At your own institution:
  • Investigate whether there is ongoing research or dedicated experiences in global surgery and reach out via email.
• Medical student groups:
  • Consider joining an interest group such as:
    • InciSioN
    • Global Surgery Student Alliance
• Social Media
  • Start following global surgery groups on twitter:
    • @GlobalSurg
    • @GSCommission
    • @HarvardPGSSC
    • @GlobalNeurosurg
    • @TheG4Alliance
      And More!
• Further Education
  • King’s College London offers a Masters in Global Health with a specific track in Global Surgery in which you will learn much more about the development and trajectory of the field, and you can develop a research project to conduct primary research in global surgery for your capstone.
  • Royal Society of Medicine – Global Surgery Summer School two days condensed course is targeted at UK and international trainees and students
  • Various other MPH and MScGH programs may have opportunities for surgical research
  • Research Fellowships
  • Program for Global Surgery and Social Change at Harvard University
  • Doris Duke Fellowship
  • Fulbright Fellowship
• Careers
  • There is no dedicated career path to becoming a global surgeon. Some surgeons have volunteered with Medecins Sans Frontieres (Doctors without Borders), Mercy Ships, or other surgical groups for short or medium term rotations. Others are enveloping global surgery into their academic career as there is a growing body of funding for and interest in peer-review publications in global surgery. There is also the critical point that global health begins locally – you can get involved with improving affordable access to surgery in your neighborhood as well.

Overall, it is an incredibly exciting time to be interested in surgery and its importance in global health. As Jim Kim, President of the World Bank, stated: “surgery is an indivisible, indispensable part of healthcare and of progress towards universal health coverage.” I encourage you to join the movement today!

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Faith Robertson is an American medical student, aspiring neurosurgeon, and global surgery enthusiast. She is presently taking a year out from Harvard Medical School to obtain an MSc in Global Health with Global Surgery at King’s College London to gain skills necessary to positively impact the field of global surgery, and be a leader in global neurosurgery efforts. Faith also serves as an International Representative for the Association of Women Surgeons National Medical Student Committee. She plans to pursue a career in Neurosurgery and Health Systems Improvement.

Twitter: @FaithCRobertson
LinkedIn: https://www.linkedin.com/in/faithrobertson/

Our blog is a forum for our members to speak, and as such, statements made here represent the opinions of the author and are not necessarily the opinion of the Association of Women Surgeons.