Surgery: A case to be included in the global health movement
By: Prativa Baral
When envisioning global health initiatives, we often think of large-scale vaccine campaigns, health promotion programs aimed at reducing the spread of infectious diseases, and easy at-home oral rehydration solutions that manage diarrhea. Surgery is much less likely to come to mind, particularly in low- and middle-income countries (LMICs) and has thus been labeled as the “neglected stepchild of global health”. It comes as no surprise then that no international funding organization focuses strictly on access to surgical care. This lack of funding is quite troubling, considering the fact that a the Global Burden of Disease study from 2010 showed a rise in several surgically treatable disorders. While an accurate assessment of the overall global burden of surgical diseases is difficult to do, a Lancet study estimated that 28–32% of patients worldwide would have significantly benefited from having access to a surgeon.
Not surprisingly, 90% of injury-related deaths occur in LMICs, where surgical operations to treat injuries are simply not that feasible, nor accessible. The infrastructure in some LMICs is so fragmented that clean water, oxygen, electricity, and anaesthetics are severely lacking, making it very difficult to perform even the most basic life-saving operations. In addition, LMICs perpetually face gaps in healthcare accessibility such that prevention and public health efforts rarely consider how individuals might access surgical procedures.
Focus on Infectious Diseases
Global health has, for the most part, focused on communicable infectious diseases such as AIDS and smallpox, and understandably so. From a health promotion standpoint, it’s easier to disperse some responsibility to the public by distributing messages that are focused on a single infectious disease which can be tackled through relatively simpler hand-washing or vaccination campaigns. Since surgical interventions rarely deal with transmission from one person to another and do not have the threat of pandemics associated with them, public support is just not there. As such, the treatment of surgical diseases has been awarded to patients who can pay for the services: an immense barrier to those who need it the most. This is especially tragic because the world’s rural poor in low-income countries are disproportionately affected by surgical conditions.
Cost-effective, short-term and long-term
There is a common misconception that exists regarding the costs associated with surgery. Often times, we associate fancy equipment, white walls, and beeping machines in an isolated hospital room with surgical procedures. This expensive and complex perception is a barrier to the acceptance of surgery in global health efforts. It should be noted that basic and cheap life-saving surgeries for a number of different medical conditions exist and have proven to be cost-effective, even in resource-poor countries. Recent cost-effectiveness studies have shown that basic surgical care is just as comparable to traditional public health interventions like vaccines. In the long run, surgery can thus be even more cost-effective than traditional interventions, as it often provides a long term solution with fewer after-effects.
Small intervention, large impact
While the Sustainable Development Goals have brought attention to key health issues in LMICs, surgically-treatable disorders have not been specifically addressed. These are likely to play a largely debilitating role in people’s lives. For example, simple interventions such as cataract surgery that restores vision is life-changing, drastically improving the quality of life and benefiting the individual and the community economically. Individuals who undergo this surgery are able to socially and economically contribute to their community. In addition, family members who would have otherwise been limited to a caregiving role are now free to pursue their educational, economic and social needs. Similarly, surgery for victims of facial congenital anomalies or burn injuries have been found to result in long-term clinical and economic benefits for the patients, whose potential would have been hindered otherwise. It should go without saying that other surgical interventions such as emergency obstetric care would also play an immense role in reducing a significant portion of the 287 000 maternal deaths that occur every year, of which 99% are from LMICs.
Long-term investment
In LMICs, there are infrastructure challenges that come in the way of surgery, from the lack of operating rooms, electricity, laboratory services, and anaesthesia, to the lack of surgically trained health-care providers. While most cost-benefit analyses take these limited resources into account, initial infrastructure investment may prove to be a challenge. However, when looking at the costs spread out over time, the surgical volume as well as the overall return, this initial investment is very cost-effective. It is so important then that an initial investment be allocated to strengthen the overall health system to address these infrastructure needs, instead of relying on short-term surgical relief through medical missions. While the latter play an essential role, particularly during humanitarian crises, they are not equipped to provide the level of sustainable care that a long-term investment in surgery and local healthcare infrastructure would be able to provide.
Partners in Health
Partners in Health (PIH) has approached access to surgical care in the same way that they have approached infectious diseases like AIDS or tuberculosis. By waiving healthcare fees in Haiti for example, they’ve given surgical access to the very people that need it the most but would not have been able to afford the care otherwise. PIH’s Right to Health program also assists patients that require more complex surgical care with the tools needed (medical counseling, financial travel support) to ensure that patients receive the care as seamlessly as possible. For instance, Samatha Cadet was flown to Syracuse, NY from Haiti to undergo an extensive heart surgery, which would otherwise not have been available to her at home.
Ultimately, surgery should be recognized as a cost-effective primary care intervention in LMICs. If we believe that health is a human right (as we should), no individual should neglect their health condition to the point of life-long disability or death. No practitioner should provide more care than needed because of neglect due to limited access to care. While the infrastructure and health systems in resource-limited countries commonly have led to the neglect of surgery as a viable option in primary care, strengthening access to basic surgical care, as Partners in Health has done, is crucial in providing life-saving and disability-preventing services. It is estimated that only 3.5% of the 234 million surgical procedures performed globally each year take place in low-income countries. Improving the local surgical capacity in the global health movement would be an excellent way forward in confronting this massive global health inequity.
