Two teenage girls in obstructed labour were evacuated to a hospital in South Sudan. One died on the plane. The other had her ruptured uterus repaired and her life saved. Their fates were separated only by the minutes taken to reach a functioning operating room.
That margin between life and death is the overlooked story of global surgery at a time when nearly a third of the global disease burden and 15 per cent of world disability require surgical intervention. Examples include pregnancy complications, trauma, cancer, serious infections and chronic conditions.
But five billion people – nine of every 10 people in low and lower-middle income countries – cannot get safe, affordable surgical attention. That costs 17 million lives annually, nearly six-fold the roughly three million dying from HIV, tuberculosis and malaria that attract billions of dollars. Why is surgery the neglected step-child of global health?
It is partly a trick of the mind. No one plans to break their leg or develop cancer; and once surgery mends them, it fades from thought – unlike the continuous risk of malaria or the lifelong therapy of diabetes.
And partly it is the tyranny of the measurable: global health interventions favour the clean narrative of straightforward conditions with clear metrics, while surgery rejects that tidiness. It is not a magic potion but part of a complex healing system that is harder to photograph, applaud and fund.
The neglect turns concrete when we follow the money. A review of African national health strategies found that one in five did not mention surgery at all, and none made significant budgetary provision. Of the roughly $30 billion a year in foreign aid for health, the portion going to surgery is also unknown.
Apparently, such statistics are not considered worth tracking – despite the targets set in 2015, the year the Sustainable Development Goals were adopted. They proposed doing 5,000 procedures per 100,000 population by 2030 and ensuring that 80 per cent of people could access essential surgery within two hours. That called for 143 million additional operations each year.
Most damning is that these data come from the 2015 Lancet Commission on Global Surgery. We are arguing today’s case on decade-old evidence. Despite growing global health research, why is it thought not worth the trouble to count again? The further irony is that recent aid cuts and diversion of national social spending towards security mean the near-extinction of the surveillance systems that could do the tracking.
Undoubtedly, a fresh census would expose a widened gap. Not least because of population increase and ageing. Projections indicate that the surgically excluded population has risen to six billion today and unmet needs to 160 million procedures annually.
The surgical gap is set to further widen even as the overall ambition for universal health coverage falls considerably short of its 2030 milestones. The short-sighted element is the failure to recognise surgery’s catalytic role as the “golden thread” that stitches health services together.
Consider the average district hospital in a developing country without reliable surgical facilities. A surgeon arrives to demand reliable electricity, water, oxygen, and a blood bank, laboratory, diagnostics, pharmacy, uncompromised hygiene and trained nurses. The whole enterprise is required to get upgraded with direct benefits for all patients.
Then, along comes an earthquake or other disaster, a disease outbreak or an influx from violence or war. The early responders are often surgically skilled, as in pandemics such as Ebola currently raging in Democratic Republic of Congo. Or the rescue teams following the Venezuelan and Colombian earthquakes. Their training, equipment and safety protocols allow them to turn quickly towards handling seriously traumatised, sick or infectious patients. They are the real frontline of national and global health security.
The development case is even more striking. For adequate surgical coverage, low and lower-middle income countries should invest about 0.5 per cent of gross domestic product per capita to avert the loss of 2 per cent of annual growth from surgically avertable mortality and morbidity. That is just $5 per capita in poor African states – a small part of the $40 they spend overall on health and an even smaller proportion of the $250 that should ideally be spent in delivering core universal health coverage.
In cold economics language, surgical scale-up is a best buy for health care, especially amid constrained financing scenarios. There is no policy disagreement: several World Health Assembly resolutions set directions for appropriate surgical development. But, beyond the modest funding requirements are contradictory influences that stymie progress.
First is the lure of glamorous interventions even as essentials are neglected. Take the booming market in cosmetic surgery valued at $60 billion annually, much of which is unnecessary. On the other hand, more than 600,000 non-lucrative cleft palates and lips in poor communities go unrepaired, causing untold disability and distress.
Meanwhile, an astounding revolution in surgical technologies and techniques is under way using robotics and artificial intelligence. Proponents postulate huge benefits but only if millions are first invested in new infrastructure and costly machinery. Driven by private finance seeking good returns, this is no panacea for publicly funded care in low and lower-middle income countries where the simple test for a basic surgical facility is to safely perform three “bellwether” procedures: caesareans, laparotomies and managing open fractures.
Frugal innovations exist to do these better, such as a piece of mosquito netting that costs cents to replace commercial mesh that costs hundreds of dollars to repair hernias in India. Or a drill costing $50 in a hardware shop in Malawi with a reusable sterilisable cover replacing a bone drill costing $30,000. But there is little money to be made there for the big instrumentation supply business.
However, frugal technologies are reversing back to rich nations struggling with tightening budgets. Such as ultrasound machines costing $100,000 replaced by capable versions engineered in China for $15,000. That is helped by another trend towards surgery seeking quick bedside tools in busy emergency rooms and ambulances.
Nevertheless, the shortage of surgical professionals is a critical bottleneck. Against a target of 20 surgical, anaesthetic and obstetric providers per 100,000 people, most developing countries fall short by 60-80 per cent. For example, Africa is served by just two per cent of the global surgical workforce while carrying 25 per cent of the surgical disease burden.
This is not necessarily from lack of training. Surgical professionals in developing countries, frustrated by poor working conditions, leave in droves as part of health worker migration that is equivalent to transferring millions of dollars from poor to rich states. Task-shifting solutions exist as with nurses giving anaesthesia or performing caesareans in Ethiopia but prevailing elitist “closed shop” attitudes, obstruct wider adoption.
The perverseness is that increasingly expensive provision in developed nations is leaving their own citizens untended. Thus, Canadians in terrible pain go to Latvia for timely hip replacements and Europeans go to India for affordable kidney transplantation. Under the circumstances, copying a broken, profligate rich-country surgical model is the greatest risk faced by upcoming nations. More affordable and accessible alternative approaches exist but considerable professional, institutional and political obstacles stand in the way.
Two thirds of us will, at some point, need a well-sharpened knife wielded by skilled hands. Even those who escape it will watch a loved one who does not. Ultimately, the case for a sensible model that serves all is not technical or financial. It is the simple proposition not yet taken to heart: a world capable of remote robotic surgery has no honest excuse to let anyone die, suffer or get disabled for want of basic surgical attention.
