Surgery Begins Long Before the Incision

By: Srinithya Gillipelli

During my Fulbright-Fogarty Fellowship, I spent a year in Peru studying global surgery and health policy, much of it alongside community health workers (CHWs). I arrived expecting to focus on operating rooms, surgical volume, and workforce shortages. Yet the most enduring lesson came from outside the hospital walls– for many patients, surgery does not begin in the OR. The surgical cascade begins at home, among beliefs and barriers that affect communities in many resource-limited settings.

In resource-limited settings, the distance between a patient and an operating table is rarely just geographic. It is shaped by trust, cost, timing, information, and fear. In Cameroon, nearly one in five patients presenting with a surgically treatable condition in one study ultimately declined surgery, most often because of financial and social constraints rather than medical contraindications.¹ A technically skilled surgeon and a well-equipped operating room mean little if a patient cannot move from diagnosis to decision, or from decision to arrival. 

Global surgery often measures access through surgeon density, infrastructure, and travel time.² These indicators matter, but I learned that there are many more factors to investigate in order to capture how patients experience care. Even when hospitals are reachable, patients may delay for months or years. Qualitative work across multiple low- and middle-income countries has shown that fragmented perioperative pathways, limited human resources, and direct and indirect costs–even within nominally “free” systems–shape whether patients proceed with surgery.³ In Peru, I met families who lived within reach of tertiary hospitals, yet waited until conditions became emergencies. Some did not recognize surgical disease as treatable. Others feared the health system based on prior experiences. Many could not absorb the indirect or hidden costs of transportation, lodging, or lost wages.

In the operating room, we rarely consider the barriers that preceded that moment. CHWs operate precisely in that space. They are often described as extensions of the health system, but in practice, they serve as trusted translators between institutions and communities. They help patients interpret symptoms, understand diagnoses, and anticipate what care will require. A growing body of literature highlights how CHWs strengthen linkage to operative care and support post-operative follow-up by navigating social and structural barriers.⁴ In Peru, I watched CHWs explain surgical plans in familiar language, help families plan for travel, and encourage return visits. They changed surgical trajectories without ever holding a scalpel.

Patients also conceptualize surgical disease differently than clinicians. In rural Ethiopia, communities distinguish between “problems you can live with” and true emergencies, often delaying care until function or survival is threatened.⁵ From the patient perspective, surgery is not a discrete event but a process marked by uncertainty. Outcomes are shaped by diagnosis, referral, transport, counseling, and follow-up as much as by technical execution. When these systems fail, surgeons inherit advanced diseases and preventable complications. When they function well, surgery becomes safer and more equitable.

If we aim to improve surgical outcomes globally, including within rural areas of the United States, our focus must extend beyond infrastructure. The Lancet Commission on Global Surgery emphasized that timely access requires not only proximity, but the ability to actually receive care when needed.² Meeting that goal requires integrating surgery into community-based systems and valuing the workforce that bridges patients and hospitals. It also requires training surgeons to recognize surgery as both a technical and social intervention.

After a year in Peru, I left with deeper respect for the unseen work that makes surgery possible. The scalpel matters, but so does the pathway that leads a patient to it. Surgery begins long before the incision, and our systems should reflect that truth.

Citations

1. Lerman, B. J., Alsan, M., Chia, N. J., Brown, J. A., & Wren, S. M. (2017). Beyond Infrastructure: Understanding Why Patients Decline Surgery in the Developing World: An Observational Study in Cameroon. Annals of surgery, 266(6), 975–980.https://doi.org/10.1097/SLA.0000000000002002
2. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2015;386(9993):569-624. doi:10.1016/S0140-6736(15)60160-X
3. Bedwell, G. J., Dias, P., Hahnle, L., Anaeli, A., Baker, T., Beane, A., Biccard, B. M., Bulamba, F., Delgado-Ramirez, M. B., Dullewe, N. P., Echeverri-Mallarino, V., Haniffa, R., Hewitt-Smith, A., Hoyos, A. S., Mboya, E. A., Nanimambi, J., Pearse, R., Pratheepan, A. P., Sunguya, B., Tolppa, T., … Stephens, T. J. (2022). Barriers to Quality Perioperative Care Delivery in Low- and Middle-Income Countries: A Qualitative Rapid Appraisal Study. Anesthesia and analgesia, 135(6), 1217–1232.https://doi.org/10.1213/ANE.0000000000006113
4. Li, H. W., Scanlon, M. L., Kisilu, N., & Litzelman, D. K. (2021). The role of community health workers in the surgical cascade: a scoping review. Human resources for health, 19(1), 122.https://doi.org/10.1186/s12960-021-00659-z
5. Negussie H, Getachew M, Deneke A, Tadesse A, Abdella A, Prince M, Leather A, Hanlon C, Willott C, Mayston R. “Problems you can live with” versus emergencies: how community members in rural Ethiopia contend with conditions requiring surgery. BMC Health Serv Res. 2024 Feb 16;24(1):214. doi: 10.1186/s12913-024-10620-0. PMID: 38365723; PMCID: PMC10874059.

Srinithya (Nithya) Gillipelli is a fourth-year medical student at Baylor College of Medicine. During medical school, she completed a Paul Farmer Global Surgery Research Fellowship at Harvard Medical School’s Program in Global Surgery and Social Change, as well as a Fulbright-Fogarty Fellowship in Peru focused on surgical systems strengthening and community-based care. She is interested in global reconstructive surgery, cleft care access, financial burden of surgical disease, and surgical workforce development.