INTRODUCTION
Over the past decade, the concept of surgical care as a population-based, affordable,
and globally relevant issue has gradually begun to emerge.[24
28
34
37] The facts are startling: more people die each year due to the inability to access
surgical care than from human immunodeficiency virus/acquired immune deficiency syndrome
(HIV/AIDS), tuberculosis, and malaria combined.[6] The highest incidence results from
(in descending order) accidental trauma (bone and soft-tissue injuries), tumors, obstetrical
complications (including obstetrical fistula), cataracts and glaucoma, perinatal conditions
and congenital anomalies, male circumcision (prevention of HIV transmission) and a
large group (19%) under the heading of “Other,” which include a variety of diagnoses
such as hernia, gall bladder disease, infections requiring surgical care, etc.[4
6] However, the global burden of disease (GBD) associated with surgical and obstetrical
care has yet to be adequately defined; current numbers are likely to be artificially
low.[27
36] While the total volume of actual surgical cases can be tallied, the unmet surgical
need is only beginning to be measured.[29] It is not without reason that surgery has
been termed the “neglected stepchild” of global public health and the “neglected specialty
in the current global health arena.”[7
8]
Historically, the primary barrier to developing surgical services has been the (mis)perception
that surgery is overly expensive for the majority of lower and middle income countries
(LMICs).[3] However, the World Bank published the 2nd edition of Disease Control Priorities
in Developing Countries (DCP, 2006), which provided the first clear economic evidence
that surgical care could be a cost-effective strategy under certain circumstances
when compared with other types of care, such as antiretroviral medications, vaccinations,
and other primary treatments. This economic impact was calculated on the basis of
Disability Adjusted Life Years (DALYs), which is the sum of Years of Life Lost (YLL)
plus the Years Lost due to Disability (YLDs) or simply: DALY = YLL + YLD. The purpose
of surgery, however, is to alleviate or mitigate against certain physical conditions
and the resultant “DALYs averted” reflects the reduction in calculated DALY as a consequence
of the timely institution of appropriate surgical care. Surgical conditions account
for 11% of global DALYs lost each year, with LMICs carrying the greatest burden; Southeast
Asia plus Africa alone, accounted for 54% of DALYs in 2004.[6
9]
Emergency and essential surgical care is increasingly recognized as a critical element
to improving primary health care delivery. In the World Health Report 2008—Primary
Health Care (Now more than Ever), the World Health Organization (WHO) included Surgery
for the first time within the Primary Healthcare Sphere of Care.[22
35] This report emphasized the creation of primary care teams responsible for defined
populations with access to all aspects of care, which was not splintered by economic
concerns or differences. While inserting one word on an organizational chart appears
to be a small step, it was a huge leap forward that required years of continual effort.
Additionally, WHO has made surgical care a priority.[1
20] The Emergency and Essential Surgical care (EESC) of the WHO, has been active in
the Global Initiative for Emergency and Essential Surgical Care (GIEESC), a forum
of surgical experts. EESC has published the volume Surgical Care at the District Hospital
(SCDH) in seven languages and produced the Integrated Management of Emergency and
Essential Surgical Care (IMEESC) toolkit, a Compact Disc that contains the SCDH, a
long list of best-practice protocols (including disaster management), multiple point-of-contact
posters, and a number of instructional videos. Ongoing research within EESC includes
a large database of surgical hospital capacity throughout the developing world (>700),
capacity building through educational programs, and periodic follow-up of existing
programs. Within the WHO, other areas of relating to surgery include Violence and
Injury Prevention, Maternal and Child Health, HIV/AIDS (male circumcision), and transplantation.
Surgery is credited with providing a critical role in achieving the United Nations
Millennium Development Goals (MDGs) and is most closely involved with numbers 4, 5,
and 6.[23] Although most directly linked to these MDGs, surgical care also indirectly,
but significantly contributes to MDG 1: The eradication of poverty and hunger. This
is due to the fact that restoring health to the man who is a primary provider (such
as repairing an inguinal hernia so that he can return to work) and/or the woman who
provides for the home and children (such as relieving obstructed labor or repairing
a vesico-vaginal fistula), greatly reduces economic loss and/or emotional hardship.
MDG 4: REDUCE CHILDHOOD MORTALITY
Both the 5% mortality of children under the age of 5 years resulting from injuries
(approximately 345,000 children, 95% in LMICs, 2011) and the 7.6% mortality seen in
neonatals (0-27 days) secondary to congenital anomalies (272,940, 2008), can be reduced
by timely surgical intervention. Additionally, there is a 10-fold increased risk of
premature death for over 1 million children left motherless each year, simply by not
having a mother to provide sufficient care.[17
19]
MDG 5: IMPROVE MATERNAL HEALTH
Although declining, there are over 350,000 deaths per year due to complications of
pregnancy, mainly postpartum hemorrhage and infection, both mainly treated with basic
surgical techniques. In 2010, about 800 women died per day, (of these, 440 in Sub-Saharan
Africa, 230 in Southern Asia, 5 in high-income countries). Additionally, 8% maternal
deaths are due to obstructed labor (1-5/1000 live births), resulting in 50-100,000
women developing disabling obstetric fistulae annually. There are currently an estimated
1-2 million women permanently disabled as a result of fistulae, resulting in being
outcast from family and society. The only tangible hope of returning to an acceptable
quality of life and to their community is through surgery. Additionally, approximately
68,000 women die annually from unsafe abortions.[18
21]
MDG 6: COMBAT HIV/AIDS
Male circumcision has been shown to reduce the risk of men acquiring HIV through heterosexual
intercourse by 60%.[2
10]
Significant other challenges to global surgical care are accessibility to care and
the constricted surgical workforce. An estimated 234 million surgical and obstetrical
procedures are performed globally each year, yet it is estimated that the wealthiest
4 billion people undergo 96.5% of the procedures, while the world's poorest 2 billion
undergo the remaining mere 3.5%.[5
25] On average, only 46% of births are attended by skilled personnel in Sub-Saharan
Africa, while Europe enjoys approximately 96% birthing assistance. This represents
an enormous health care disparity for surgical care, which is similarly reflected
in the requisite surgical personnel: Sub-Saharan Africa bears 24% of the GBD, yet
contains only 11% of the global population, and only 3% of the world's health workers.
Currently in Sub-Saharan Africa, on average, there is 1 surgeon per 2.5 million people
(WHO guideline: 1 surgeon/20,000 population) and 1 trained physician anesthesiologist
per 25 million people.[30]
For example, Uganda has 75 general surgeons for 27 million people (1 per 360,000);
anesthesia is provided by 350 “anesthetic officers” who have received 18 months of
training to complement a high-school qualification. Uganda also has 20 orthopedic
surgeons, 3 cardiothoracic surgeons, 3 pediatric surgeons, 6 neurosurgeons, 3 plastic
surgeons, and 3 urologists, yet this fills only 7.4% of projected need met [Figure
1].
Figure 1
Demographics from Africa on the need for surgeons
METHODS
There are currently several methods that have been utilized to provide surgical care
to LMICs. The traditional model has been to send a Western trained surgeon (generally
Caucasian) to the country's interior, generally a very remote setting with a small,
ill-equipped hospital, hoping that the surgeon would make a career of it as it is
often impossible for him or her to be replaced. This model has been in existence for
well over a hundred years; excellent examples would be Dr. Albert Schweitzer and his
hospital in Lambaréné, Gabon and Dr. David Livingstone in central and southern Africa.
This model is still, unfortunately, the prevailing paradigm throughout the developing
world, especially among faith-based organization (FBO) hospitals.
An extension of this model and the basis for its continued survival has been the utilization
of short-term (ST) surgeons who provided varying interims of service as either a stop-gap
measure or as recurring, but intermittent service. While this satisfies acute necessities,
it often fails to provide long-term results, more often positively impacting the ST
surgeon much more than the local hospital or population.
More recently, the concept of institutional “twinning” has become prevalent, where
a Western university (often a single department) partners with a similar institution
(or department) within an LMIC and develops academic relationships in surgical expertise
and/or research.[31
32] Good examples are the University of California San Francisco's Program in Surgery
and Global Health;[14
26] Harvard's Department of Global Health and Social Medicine, including the Program
in Global Surgery and Social Change;[12] Duke Global Surgery, partnering with Duke
Global Health Institute;[11
15] University of North Carolina Institute for Global Health and Infectious Diseases;[13]
and Loma Linda University Global Health Institute, among others.[16]
A newer model is one of developing surgical training programs within LMICs for training
local physicians as surgeons to care for their own people in their own country. These
individuals are much more culturally aware, communicate in local dialects, become
excellent role models to local young people, and may not suffer the frequent psychological
strains that ex-patriots are prone to exhibit. An excellent example this is the Pan-African
Academy of Christian Surgeons (PAACS) that began general surgery training programs
in Africa in 1996. PAACS now consists of eight 5-year programs, training a total of
43 residents in six countries, with a stated goal of training 100 African surgeons
by 2020.[33] Each of these programs has full accreditation from College of Surgery
of Eastern, Central and South Africa (COSECSA) and/or the West African College of
Surgeons (WACS). There are plans for additional training programs to become active
in Malawi (2013), and Tanzania (2013), and later, possibly in Togo, Nigeria, Egypt,
and Zimbabwe. There is enormous, unmet additional need for training programs in every
specialty, but particularly in Obstetrics and Gynecology, Orthopedic Surgery, and
Anesthesia.
RESULTS
To date, the results of training surgical residents in LMICs have been immensely encouraging.
This year, all finishing residents in the PAACS programs passed the fellowship (5th
year) examination in COSECSA. They are highly skilled in surgical techniques, although
a different blend of skills from Western trained surgeons. These finishing residents
have a large experience in general surgery, but also possess expertise in simple craniotomies,
radical prostatectomies, intramedullary rod placements, C-sections and deliveries,
among many others. They have a somewhat more limited exposure to Laparoscopic/minimally
invasive techniques, and endovascular procedures.
Furthermore, as both twinning opportunities and ST programs have demonstrated, there
is increase in capacity within local hospitals when these programs have been given
a chance to mature and are effective.[11]
Future prospects
The majority of surgical care in LMICs is charity care, which by definition is not
sustainable by itself; therefore, the concept that all of these hospitals should have
the goal of self-sustainability is unrealistic. Additional resources are necessary
to continue any significant surgical training and care in these institutions, in these
countries. Currently, reimbursement from local governments is grossly inadequate.
Organizational support is realized from nongovernmental organizations (NGOs), foreign
governments, and FBOs, as well as large donor organizations, such as Gates Foundation,
mostly through research and program grants funneled and implemented through university
programs or through the WHO.
Unfortunately, surgical care has been eclipsed by the global attention of infectious
disease, its treatment and expectant eradication. Additionally, disproportionally
more effort is placed on acquiring surgical equipment and supplies than for surgical
research. As greater attention is brought on surgical issues, particularly violence
and injury, maternal and pediatric issues, and surgical requirements of infectious
processes, greater efforts at requesting and obtaining research support can and will
greatly facilitate the growth of surgical services. This should be done at all levels:
Governments, NGOs, FBOs, and both large and small donors.
In addition, at each level of involvement, further emphasis must be placed on postgraduate
training. Young physicians in LMICs have a keen thirst for knowledge and skills, and
possess the requisite education for advanced training. Unless our current paradigm
shifts from single interventions and ST engagements, continuing to ignore the component
of long-term training, such interventions and associated limitations will be perpetuated
indefinitely; “the unsung volunteer heroes cannot carry the burden of developing surgical
capacity alone.”[8] However, as stronger institutional collaboration is established,
more training programs are implemented throughout LMICs and exceptional candidates
graduated and mentored into becoming trainers, the growth of surgical capacity can
become exponential and surgical training become sustainable.
ADDENDUM
For readers interested in becoming involved in international work, but initially unsure
where to turn, several possibilities exist. All are invited to join the WHO Global
Initiative for Emergency and Essential Surgical Care (GIEESC) referenced below. This
is a forum of surgeons, anesthesiologists, interested individuals and Ministries of
Health that meets biannually; the next meeting is hosted by the Ministry of Health
of Trinidad and Tobago, October 13-14, 2013. WHO also has many international partners
listed on the website below that accept volunteers.
Venturing out of one's comfort zone to medical meetings on an unfamiliar continent
is invigorating and allows one to meet and network with a large cadre of individuals.
Similarly, working with one of several different groups will expose the volunteer
to new situations without long-term commitment. A limited listing of some groups is
included below, but others can be found through NGOs, church groups, university affiliations,
etc. Any of the programs mentioned in this manuscript have associated individuals
that will be very helpful in suggesting first-rate venues for service. Another excellent
resource for those wishing to contribute to academic programs is the Fellowship for
International Education in Neurological Surgery (FIENS), although this will generally
require a one month commitment. Anyone unable to find an appropriate place to volunteer
is welcome to contact me directly.
For practicing neurosurgeons, bringing your level of expertise to other countries
and contributing in meaningful ways with local healthcare and surgical training is
profoundly rewarding. It most frequently changes the volunteer in much more significant
and enduring respects than the volunteer changes the hosting institution.