A Study in Global Surgery

Context

According to Dr Sebastian Taylor, ‘Global Surgery’ is the term coined to describe the rapidly developing multidisciplinary field, concerning the improved and equitable surgical care across international health systems, often with an explicit focus on lower middle income countries (LMIC). Although recently, Global Surgery is gaining more attention, it wasn't always this way. In 2008 Dr. Jim Yong Kim and Dr. Paul Farmer, world experts on global medicine and global health development, called surgery “the neglected stepchild of global health”. An example of this is the fact that cancer morbidity and mortality disproportionately affects LMIC; of 15 million new cancer diagnoses in 2015, over 80% will require surgery, and half of those will not have access to safe surgical care. This shows that surgery has low priority in global health planning, so the delivery of surgical care in low-and middle-income countries is often poorly resourced. In fact, over 90% of injury deaths occur in LMICs, accounting for more deaths than AIDS, TB, or malaria combined in children over the age of five. Yet, funding towards surgical development has historically accounted for less than 1% of the World Health Organization’s budget. This lack of funding raises additional issues such as shortage of personnel, lack of appropriate training, failure to establish surgical standards, as well as failure to appreciate local needs and poor coordination of service delivery. Africa, for example, has only 1% as many surgeons as the United States. And overall, 5 billion people around the world do not have adequate access to basic surgical care, with the poorest 30% of the world receiving only 3-6% of operations, and the richest 30%, receiving 75% of operations.

Global Surgery Awareness Programs

To combat the issues regarding surgery, John Hopkins launched the Johns Hopkins Global Surgery Initiative (JHGSI). The initiative was aimed at promoting health, equity, and justice by improving surgical care across the globe. They emphasized the value of interdisciplinary and international collaboration, holding the belief that diversity in background and experience will help better achieve their vision. Harvard Medical School is also working towards the globalization of surgery through their collaboration with Paul Farmer. In addition to these, there are various research opportunities, internships, and fellowship programs offering for the globalization of surgery awareness. Global Surgery committees, speakers, and separate abstract tracks have been added to most major surgical conferences. Furthermore, the American College of Surgeons is also starting collaborative training initiatives in sub-Saharan Africa, and global surgery centers are sprouting at major academic institutions. Because of this, between 2005 and 2015, research publications in the field of global surgery increased from approximately 570 articles in 2005 to more than 4,000 articles published in 2015, according to PubMed.

Medicare

A major aspect of Global Surgery is Medicare, or the pre-operative and post-operative care procedures. Pre-operative visits are visits that are made following the decision to perform surgery. For major procedures, this includes pre-operative visits before the day of surgery. For minor procedures, this includes pre-operative visits the day of surgery. Additionally, following a surgery, follow-up visits during the postoperative period of the surgery that are related to recovery from the surgery are also an aspect of Medicare. Often, surgeons will provide pain medication, some supplies, and miscellaneous services, such as dressing changes, local incision care, removal of operative pack, removal of cutaneous sutures and staples, lines, wires, tubes, drains, casts, and splints; insertion, irrigation, and removal of urinary catheters, routine peripheral intravenous lines, nasogastric and rectal tubes; and changes and removal of tracheostomy tubes.

IONM

Intraoperative services are a part of Medicare which are normally a usual and necessary part of a surgical procedure. For instance, intraoperative neuromonitoring (IONM) protects patients by continuously monitoring the central nervous system (the brain, spinal cord, and nerves) when it is at risk during surgery. Depending on the procedure, a variety of tests can be used to measure the nervous system function. IONM provides an extra layer of safety for both the surgeon and most importantly, the patient.

Difficulties

Even when the need for surgery is clearly identified, it is difficult to classify and measure, because no universal nosology for surgical conditions or treatment exists. Surgery's cross-cutting nature means that classification of surgical conditions overlaps with classification of all other disease subsets. For example, is colon cancer—incurable without surgical intervention—characterized as a surgical condition or a malignancy? Is sepsis from an infected diabetic foot wound necessitating amputation an infectious disease, endocrine disorder, or surgical ailment? Is obstructed labor, for which instrumental or operative intervention is the only definitive treatment, considered a maternal health or surgical problem? Unlike a discrete disease entity, surgery is a treatment modality and is needed across the entire range of human disease. The scope of this need further complicates measurement of the prevalence and effect of surgical conditions. Research shows that major procedures are undertaken in every disease subcategory defined by the Global Burden of Disease (GBD) study (figure 1); at least 15% of pregnancies result in complications that need emergency obstetric care, including surgical management; and surgery is responsible for roughly 65% of all cancer cure and control. Although not every trauma patient who has a severe physical injury needs a surgical procedure, care of injured patients almost always needs the skill of a surgically trained provider.

Lancet Commission on Global Surgery

Their vision is universal access to safe, affordable surgical and anesthesia care when needed. To quantify a more comprehensive assessment of access in terms of this vision, we created a mathematical model to show how many people worldwide are unable to receive safe, timely surgical and anesthesia care with financial protection. They defined access to surgery in a specific country by the following four components: existence of surgical capacity in terms of workforce and infrastructure; ability to obtain surgical and anesthesia care in a timely way; a safe way; and an affordable way. They hope that the Commission's findings will draw attention to the gross disparities that exist worldwide in surgical care, and the far-reaching human and economic consequences that result in lost lives, lost potential, and lost output. We also hope that this report serves as a catalyst and provides an early framework to effect change. The problems are clear. The solutions will need continuing development, testing, and refinement. Only through a unified commitment to research, advocacy, policy development, and investment, accompanied by coordinated local and international action, will this Commission's vision of universal access to safe, affordable surgical and anesthesia care when needed be realized in our global community.

Ethics in Global Surgery

The academic surgical community has identified the importance of ethical considerations in Global Surgery and acknowledge that the best ethical standards and practices are not always realized. In this setting, ethical practice extends beyond individual patient care to encompass education, partnership and collaboration, and research. A notable gap in the literature was found in the paucity of reporting from LMIC institutions. This perhaps illustrates the crux of the issue with ethics: ethical and equitable solutions cannot be achieved unless and until all stakeholders are present at the table. Given that LMICs are frequently the recipients of global surgical initiatives, the relative absence of their voice in the literature reviewed is a substantive deficiency that requires urgent attention. Any attempt to address the ethical considerations that arise in these collaborations must take into account the perspectives and experiences of the LMIC participants. The lack of original research is a concern, not because ethical principles are empirically derived, but because global surgical ethics should be informed by the experiences of the patients, families and communities that these surgical missions are meant to serve. Similarly, because addressing the disparity in access to the benefits of surgery worldwide requires sustainable, collaborative partnerships to be established, the limited attention in the literature to the ethics of these partnerships in the delivery of surgical care is another gap that requires focused attention. Without meaningful stakeholder input into the current ethical discourse it is likely that domains of concern, and the broader range of perspectives required to inform them, are missing. The authors hope that this literature review will stimulate more primary research in this field of study with more equitable representation from LMIC partners.

Conclusion

Although Global Surgery has been something that has been unheard of in the past, it’s increasingly becoming more important and utilized as an effective method to help improve the physical state of individuals following an injury. Various procedures are being undertaken to increase the accessibility of surgery to everyone, including those in low-income areas. However, in order to continue to spread awareness, it is important that students and adults alike educate themselves about Global Surgery.