A Crucial Role for Surgery in Reaching the UN Millennium Development Goals

In the June 2008 issue of PLoS Medicine, Doruk Ozgediz and Robert Riviello made a convincing case that surgical conditions should be considered as “neglected diseases” disproportionately affecting the world’s poorest people [1]. “Patients with untreated surgical conditions,” they wrote, “as well as the local clinicians struggling to care for them, must gain greater recognition by the global public health community.” We welcome their call to bring surgery into the global health conversation. There are at least five important reasons why providing surgery should be considered a global public health priority. The first is that surgical conditions—defined by Haile Debas and colleagues as conditions that require suture, incision, excision, manipulation, or other invasive procedures that usually, but not always, require local, regional, or general anesthesia [2]—constitute a substantial global burden of disease. In an innovative attempt to measure the burden of surgical conditions, Debas and colleagues estimated that these comprise 11% of the world’s disabilityadjusted life years (DALYs; one DALY represents the loss of one year of equivalent full health) [2]. Africa faces the world’s highest regional rate of surgical DALYs (38 per 1,000 people) [2]. The surgical burden of disease is led by injuries, followed by malignancies, congenital anomalies, pregnancy complications, cataracts, and perinatal conditions. Debas and colleagues state that when they searched the medical literature they found “no data of value except maybe for cataracts” to inform their estimates [2]. They therefore used an international survey of 32 surgeons, 18 of whom returned completed questionnaires, a methodology that leaves substantial uncertainty around the authors’ 11% estimate. Such uncertainty calls for a concerted, coordinated effort to conduct a more formal evaluation of global surgical DALYs. The second reason to consider surgery as a global public health issue is the emerging evidence of global disparities in surgical care. While the poor world has a greater burden of surgical disease, it receives less surgical services. In a recent modeling study, Thomas Weiser and colleagues estimated that there are 234.2 million major surgical procedures worldwide each year, with 30% of the world’s population receiving 73.6% of these procedures and the poorest third receiving only 3.5% [3]. Such data suggest an “enormous unmet need for surgical care in poor countries” [4]. The third reason is that surgery can be remarkably cost-effective when compared with interventions that are considered the building blocks of global public health, such as childhood vaccination. The common perception that surgical care is too expensive and is merely “a luxury in poor countries” has persisted for too long [5]. The cost per surgical DALY averted by providing surgical care at a district hospital in Africa is estimated to be only US$33 (range US$19–US$102) [2]. This figure compares favorably with, for example, the traditional expanded program on immunization (US$7 per DALY averted) or integrated management of childhood illness (US$39 per DALY averted) [6]. A fourth reason is the possibility that building surgical services, which requires infrastructure, supplies, and human resources, may in turn help to build health systems and to strengthen primary care. Surgery can itself, of course, be a form of primary health care, as in managing traumatic joint dislocations, treating open fractures to prevent osteomyelitis, and draining abscesses [7]. Surgeons working in Africa tell us that when they provide surgery at the district level it can act as “an enabler,” raising the overall quality of health care and encouraging patients to seek medical attention for other nonsurgical conditions. We acknowledge that these are anecdotal experiences and that it would be valuable to formally evaluate the role of surgical services in health systems strengthening. A final reason is that—despite considerable hurdles, particularly the human resources crisis in sub-Saharan Africa [8]—it is feasible to deliver surgical services even in the most resource-constrained settings. Louise Ivers and colleagues, for example, have described how they scaled up surgical services over a 20-year period in a rural, isolated, and resource-poor setting in Haiti [9]. The program was provided through the public sector by the nonprofit organization Partners in Health (http://www.pih.org/), integrated with primary health services, and offered free of charge to patients unable to pay. While it is obviously more complicated to provide surgical services than many other public health interventions, such as bed-nets, nevertheless surgery is not just the preserve of high-tech tertiary referral hospitals. Many surgical interventions can be provided at the district level and some life-saving operations, such as caesarean section, can be performed by trained non-physicians [10]. Mozambique, for example, began training non-physician surgeons (técnicos de cirurgia) in 1984, a program involving a three-year degree followed by two years of supervised work in a teaching institution [10,11]. A 1996 A Crucial Role for Surgery in Reaching the UN Millennium Development Goals