Jan. 17 2017

The Global Surgical Disease Burden: a Problem Worth Solving

Every day around the world, people are affected by illnesses that cannot be cured with medicines. A worker’s arm is broken and both his health and livelihood spiral. A long-inflamed appendix bursts and takes a life. These problems have solutions, but those solutions have long been viewed in the world of public health as privileged ones because they require an operating room. As we begin to pay more attention to issues that have been overlooked by public health officials in the past, new evidence sheds light on the fact that we can no longer ignore the global burden of surgical disease.

In 2013, the multidisciplinary Lancet Commission on Global Surgery was formed to assess the worldwide surgical burden and technology and the economics of delivering surgical care on a global scale. Their findings were staggering. The commission’s 2015 report found that over 5 billion people worldwide lack access to safe, affordable surgical care. This constitutes over half of the world’s population. Like many arenas of public health, the areas of highest need are concentrated in low and middle income countries. By commission estimates, over 143 million additional surgical procedures will be needed yearly to prevent excess morbidity and mortality.

Despite this need, public health has been slow to address the global surgical disease burden.  We can accept that surgery is an indispensable part of healthcare, and we can accept that the lack of operating room availability is a major cause of morbidity and mortality worldwide—by the commission estimates, surgical emergencies cause more global disease fatalities than HIV, tuberculosis, and malaria combined. Despite the high cost of antiretroviral therapy and the difficulties of implementing sanitation infrastructure, public health has acted to address these problems. Why is it that we act slowly when it comes to global surgical infrastructure development?

It can no longer be argued that funding surgical training or infrastructure abroad has a poor return on investment. According to the Lancet Commission estimates, low and middle income countries may forfeit up to 2 percent of GDP growth by 2030 if they cannot address their surgical disease burdens. Because catastrophic health expenditure affects millions of people after surgery worldwide, failing to address this issue has major implications for both individuals and nations. While the commission estimates the cost of meeting their standard of 20-40 surgical providers per 100,000 people at 350 billion dollars, the total loss in GDP for failing to expand surgical access is estimated to be 12.3 trillion dollars.

So, if expanding the global surgical infrastructure and training an additional 2 million surgical providers is not only necessary for adequate healthcare but also an economically sound investment, then why have we been so reticent to address the problem? Perhaps it is because the cultural paradigm shift in public health from infectious diseases has been towards chronic diseases that are also often treated with medicines. Perhaps we lack the expertise. Who will know what the necessary equipment are, and what safe, economic ways surgeries can be performed, except surgeons? Who will train surgeons, except other surgeons?

Part of the problem lies in the fact that the army of public health surgeons is profoundly lacking in number. Plenty of physicians train in public health, but those physicians come largely from primary care backgrounds which are ill-suited to address this problem. While there are many individual examples of surgeons exhibiting excellence in global surgery, these endeavors are too often isolated and unitary. Surgeons must mobilize to act on the global need, and train in the public health practice necessary to fill the vacuum in our ability to address the global surgical disease burden.

Another part of the problem is that public health has traditionally failed to make space for surgeons. Public health leaders must do a better job of recruiting surgeons and those with a mind toward surgical infrastructure development if we are to adequately address this problem. One step that public health schools can take is to devote resources to offices of global surgery and recruit surgical faculty to lead them.

Further effectiveness research based on intervention, economic feasibility, and other such measures are squarely within the purview of public health. It will be important to guide this research within the broader context of surgical care at the population level: this cross-disciplinary view will best be espoused by public health surgeons. To date, they are too few in number to address the magnitude of the problem alone, but this is a problem we must solve. In order to tackle the global surgical disease burden, we must restructure our institutions to empower a generation of leaders in global surgery.

—Ali Rae