Global Surgery: imperative, controversy and opportunity

Four billion people worldwide lack access to surgical care. This striking figure stems from the scarcity of surgical capacity – workforce and infrastructure – and deadly low standards of safety, timeliness, and affordability – respectively assessed by operative mortality below 1%, access to an operating theatre under two hours, and protection from catastrophic expenditure. These critically unmet needs have grown in visibility over the past decade through the multi-dimensional approach of Global Surgery (GS).

Although mostly left to charitable responders until early 2000s, GS advocacy is currently driven by academics and health policy agencies rather than on humanitarian grounds. Strong cost-effectiveness evidence has elicited an economic approach, enticing the World Bank and national governments to scale up allocated resources. Integrating surgical activities to primary health – directly, like C-section, or indirectly, by investing in structures and workforce, have embedded them in the Universal Health Coverage dynamic. Still, humanitarians have had a role-defining part in surgical care since Napoleonian wars, and Non-Governmental Organisations (NGOs) expertise could be decisive.

Unless controversies should disqualify their contribution? The 2010 Haiti earthquake established a cornerstone, raising “serious concerns about the clinical competence and practices of some [Foreign Medical Teams (FMT)]”(1)Nickerson JW et al., “Surgical Care during Humanitarian Crises: A Systematic Review of Published Surgical Caseload Data from Foreign Medical Teams”, Prehospital and Disaster Medicine, April 2012, p.184-189., and a harsh criticism of uncoordinated post-colonial voluntourism. Since then, studies revealed a lack of evidence-based results(2)Gosselin RA et al., “Challenges of Meeting Surgical Needs in the Developing World”, World Journal of Surgery, February 2011, p.258-261.,poor cost-effectiveness, and appalling post-operative mortality figures – up to 20-fold the baseline for routine procedures(3)Shrime MG et al., “Charitable Platforms in Global Surgery: A Systematic Review of their Effectiveness, Cost-Effectiveness, Sustainability, and Role Training”, World Journal of Surgery, January 2015, p.10-20.]. But the critics blurred the thousands of life-saving and disability-averting surgical procedures performed within days of the earthquake, and the following directions in which NGOs’ input can prove vital.

Disaster response. As resilient as national surgical resources may become, anticipated large-scale disasters, exceeding local responders’ capacities, call for readily available international resources. Modern warfare accounts for a number of surgical victims expected by the WHO to increase, and war, as in Syria, can obliterate the level of existent healthcare. Provided they reflect on adequate intervention strategies, NGOs can alleviate human suffering in such contexts.

Research. About 400 aid organisations perform 200,000 surgical procedures annually in low and middle income countries (LMICs). The diversity of their operational platforms and terms of reference – from quick and dirty “Blitz Surgery” to highly specialised procedures – is a fertile research field, as GS calls for probing data. Often bound to report and re-assess their strategies through monitoring procedures, NGOs dedicate resources to collect and analyse data, enabling them to publish evidence and guidelines addressing medico-logistical challenges.

Capacity-building. While only national planification can scale GS up in LMIC, GS advocates acknowledge the need for humanitarian funding and partnerships with richer countries. The substantial budget of training is absent from their cost analysis, and foreigners could provide peer education – a paradigm intrinsic to medical practice, but complicated where specialists are lacking – to a first generation of skilled anaesthetists and surgeons.

Implementation strategy. The availability of implementation evidence is as paramount as medical evidence for GS, yet existing international recommendations lack precision and consensus. Used to rapidly assess and respond to population needs, manage complex operations, and transfer knowledge, NGOs can contribute to such implementation science. They have already been involved with the Lancet Commission on Global Surgery Network to design a need assessment frame, implementation tools and proxy indicators.

With the encouraging international reception of GS advocacy, by 2030, decision-makers at national and organization level should benefit from increased funding for surgical programs. There is a call to associate the non-profit sector to reach this goal. Responding this appeal is, for NGOs, not only an imperative, considering the disproportionate burden of untreated surgical conditions, but an opportunity to extend the comprehensiveness of, and reflect on, their relief strategies. 

Since 2008, Clairanne Bost has been regularly involved with Doctors without Borders and Alima as a nurse specialized in anaesthesia, disaster medicine and emergency obstetrics (Sierra Leone, DRC, Pakistan, Iraq, Guinea, CAR). In 2017, she began the Master of Public Health at the University of Geneva (MAS-SP) in order to promote evidence-based thinking in the fields of Global Surgery and medical response to collective emergencies. At the same time, she is a clinical anaesthetist nurse at the cantonal hospital and, convinced of the relevance of the commitment of civil society, a first aid instructor for both Geneva adolescents (Swiss Emergency Responders) and humanitarian actors working in unstable contexts (Safer Edge).

Photo description: The ICRC mobile surgical team is being deployed since September 2017. They offer primary health care and a maternity. The team of the operation theatre can do quite complicated surgeries, despite having to work with limited resources. The vast majority of the patients suffers from gunshots, but the mobile surgical team can also do other emergency surgeries.

email

   [ + ]

1. Nickerson JW et al., “Surgical Care during Humanitarian Crises: A Systematic Review of Published Surgical Caseload Data from Foreign Medical Teams”, Prehospital and Disaster Medicine, April 2012, p.184-189.
2. Gosselin RA et al., “Challenges of Meeting Surgical Needs in the Developing World”, World Journal of Surgery, February 2011, p.258-261.
3. Shrime MG et al., “Charitable Platforms in Global Surgery: A Systematic Review of their Effectiveness, Cost-Effectiveness, Sustainability, and Role Training”, World Journal of Surgery, January 2015, p.10-20.