Building a safe surgical infrastructure worldwide can save more than 17 million lives a year.
This article was written by Alicia Bonner Ness, the Editor of The New Global Citizen and the Senior Manager for Public Affairs at PYXERA Global.
I remember with absolute clarity the moments before and after my appendix was removed. The procedure, performed laparoscopically, with a tiny laser and laparoscope inserted into my abdomen, took less than two hours and, once healed, left no scar. I was allowed to remain in the hospital for the rest of the day as I gradually regained my strength and, that evening, I was discharged.
I imagine most clinicians would argue that an appendectomy is one of the lowest-risk procedures a surgeon can perform. When I entered the emergency room that evening, it never occurred to me that an ailment that required surgery could pose a risk as a patient. Yet, in many places around the world, the same simple ailment could have easily led to my death.
Creating environments where safe surgery is available to all those who need it is a tricky problem to solve. In 2014, Dr. Jim Yong Kim, the president of the World Bank, identified it as one of the most important challenges facing the world. Almost a third of the global burden of disease is treatable with surgery — yet 5 billion people around the world lack access to safe surgical intervention, and every year, around 143 million surgical procedures are not performed due to the absence of necessary personnel or infrastructure, according to a recent report by the Lancet Commission. In 2010, 16.9 million people died from conditions needing surgery, more than four times the number who died from HIV/AIDS, TB and malaria, combined.
The problems that lead to these outcomes are many, but they can be simplified into several key areas.
Finance presents a key obstacle. In most of the world, necessary surgeries are prohibitively expensive. The 3 billion people worldwide who live on less than ₵7.46 ($2) a day cannot afford to pay for any surgery when they need it, and insurance is widely unavailable. Information management is another; few countries have robust IT infrastructure to monitor patients and outcomes.
Many countries also do not have the necessary workforce or infrastructure to provide a safe surgical environment, and even in places where safe surgery is available, three delays often keep people from undergoing a necessary procedure until it is too late.
The first delay is how long it takes the patient to decide to seek care. The second delay is how long it takes a patient to reach care. The third delay is how long it takes for a patient to receive care.
In places where health systems are not as strong, this seamless healthcare pipeline is often missing. While most urban centers worldwide have health facilities that can provide some surgical procedures, the great majority of the world’s people, who live in rural environments, live hours or days away from even a district health center. Poor roads and the absence of transport means many patients die in transit.
Once a patient reaches the closest medical facility, there’s no guarantee a qualified provider will be available to provide care. Many countries have tiered healthcare systems that offer different levels of service at the district and regional level. This means that a patient may travel a long distance to a health facility only to be triaged to another long journey to the next one.
Building a Safe Emergency Care and Surgery Ecosystem
The issues of medical personnel and infrastructure are each complex in their own right, but also inherently interwoven. I recently attended the GE Developing Health Summit, which brought together the GE Foundation’s partners in global health. During the summit, I learned a great deal about how different partners are improving the ecosystem to make surgery accessible to those who need it.
Achieving the Lancet Commission targets requires that, in places where surgery is either unavailable or dangerous, governments work to reinforce all the necessary components of a healthy surgical infrastructure. This requires a framework approach: improving workforce capabilities through training, developing systems to ensure effective delivery of care and investing in infrastructure development at every level of care.
In most countries, there are not enough trained personnel to provide the surgical services for which there is demand. Rachel Moresky is an assistant professor of emergency medicine and public health at Columbia University and the founder of sidHARTe, an initiative of the Mailman School of Public Health that works in Rwanda, Ghana, Kenya, Cambodia and Honduras to live up to its name: Systems Improvement at District Hospitals and Regional Training of Emergency Care. Moresky points out that there are more doctors in Columbia’s Department of Medicine than there are in all of Rwanda.
Working under the direction of Rwanda’s Ministry of Health, sidHARTe reduces the number of fatalities at the district level by providing a one-year emergency medicine certification to Rwandan general practitioners. In Ghana, sidHARTe is working with the Ghana Health Service to provide similar training for physician assistants. Available, accessible, quality and timely emergency care at all levels of the health system are essential to diagnose and treat emergency conditions, as well as identify and stabilize acutely ill surgical patients so that they receive timely surgical care.
Bernard Olayo, chair of the Center for Public Health and Development in Kenya, is working to increase the number of Kenyans who have access to safe anesthesia, where the ratio of surgeons to anesthesiologists is 13 to one. In 2010, the center — along with the University of Vanderbilt, Kijabe, a local hospital and Kenya Society of Anesthesia — worked with the government to change its laws to allow nurse anesthetists to assist surgeons with anesthesia. The center is focused on filling the human capital gap needed to utilize advances in technology. GE, for example, has donated millions of dollars of anesthesia equipment that has gone unused because there are no trained staff to use it, which is why the GE Foundation funds the training program.
Initiatives like those undertaken by Drs. Olayo and Moresky are only two examples of the myriad interventions needed to diagnosis and treat emergency patients, as well as reach the safe surgery goals. In addition to personnel, there’s great need for on-the-ground capacity — blood banks, oxygen bottling, sterilization facilities, not to mention surgical tools and equipment. The Lancet report suggests that institutionalizing the ability to perform just three procedures can generate a great deal of progress: a facility that can safely perform an emergency C-section, can treat an open fracture (a bone that has broken through the skin), and can perform a laparotomy, an invasive surgical exploration of the abdomen that allows a surgeon to safely operate on numerous internal organs.
Reaching the Lancet Commission targets will require spending $230 billion. But it’s worth the investment. The economic loss due to the absence of surgical access is estimated to be 2 percent of GDP for countries where it is unavailable. The multi-billion dollar investment is expected to generate growth of $12.3trillion, a return on investment that is well worth the cost.
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