“Is the international surgical community ready to prepare training modules for essential surgery?”
Dr. Halfdan Mahler, Director General of the World Health Organization (WHO), made this question 40 years ago. He pointed out for the first time that the vast majority of the world’s population has no access to skilled surgical care and that surgical first aid is an essential part of primary health care.
Surgical need transects all disease categories.
“The era of only the best for the few and nothing for the many is drawing to a close”, he stated.
Global surgery is an area of study, research, practise and advocacy that seeks to improve health outcomes and achieve health equity for all people who need surgical and anesthesia care, with a special emphasis on underserved populations and populations in crisis.
This new approach regarding the urgent need for surgical care and its human and economic impact led to the aim of developing safe, essential, life-saving surgical and anesthesia care in low-income and middle-income countries (LMICs).
In 2014 the Lancet Commission on Global Surgery was launched to address crucial gaps in surgical care worldwide. Some of the data extracted is the following:
313 million surgical procedures are performed worldwide each year. Of these, only 6% are performed in the poorest countries (where one third of the world’s population lives).
5 billion people lack acces to safe, affordable surgical and anesthesia care.
An estimated 16.9 million lives (32.9% of all deaths worldwide) were lost in 2010 from conditions needing surgical care. This number of deaths surpasses deaths from HIV/AIDS, tuberculosis and malaria combined.
Common and easily treatable illnesses are translated into fatalities in the abscence of surgical care.
A goal of 5,000 operations per 100,000 population by 2030 has been set, and a surgical scale-up is needed to reach it. Other goals were:
Minimum of 80% coverage of essential surgical services.
20 surgical, anesthesia and obstetric physicals per 100,000 population.
In order to advance the cause of global surgery a holistic and inclusive approach must be taken so that all members of the surgical team are involved, supported and promoted.
The principles of healthcare ethics defined by Tom Beauchamp and James Childress are:
Surgical tourism, specially in high trauma burden countries with short-term experiences can be beneficial for both the visitor and the host but certain ethical issues must be considered, specially regarding the patient. Cultural and language barriers, limited informed consent, and lack of supervision can compromise the patient’s rights. Also, foreign personnel may not be welcome by local personnel and face hostile or unsafe environmental conditions.
Studies from LMICs have been increasing in the past years, even though geographical disparities are obvious, with a lack of patient’s information in Africa and Latin America. Big data on short and long term results can help improve outcomes and should be promoted and funded.
Sustainable strategies for providing surgical care are needed. This effective resource allocation needs a bilateral clinical, research and education collaboration between LMICs and high-income countries. This cross-continental collaboration requires the training of global surgeons.
The effective academic global surgeon integrates education, clinical service, research and advocacy. But this kind of career meets many obstacles in the way, such as the lack of funding or the lack of academic legitimacy.
A global surgical niche should be developed, founded on the maximization of existing resources, database creation and clinical research collaborations.
New academic programs and awards tend to parallel international and home academic work.
Training and accrediting international surgeons is a complete process that includes specific competencies and surgical skills.
Surgical skills can be measured with a surgical scale, whose contents are unique to each surgical specialty. Some of the basic requirements for a global surgeon would be:
- Board certification in surgery and local medical licence
- Additional training for surgeries not performed routinely
- Knowledge of the local health system
- Knowledge of the local medical-legal system
- Understanding the ethical principles of working in a low-resource environment
- Knowledge of the local disease burden and local infrastructure
- Local culture and language
Basic surgical skills should include the following: basic laparoscopy, appendectomy, inguinal hernia repair, hysterectomy, cholecystectomy, close and open fracture stabilization, burns care, splenectomy, fasciotomy, basic vascular access and control, cesarean section, management of bowel obstruction and perforation, tube thoracostomy, wound debridement and percutaneous drainage.
In summary, inequity in surgical conditions worldwide has historically been unrecognized and it causes a large number of victims. Every year, 140 million people need surgical procedures and have no access to them, especially in LMICs. Widespread provision of basic surgical services and prompt action are needed to cope with the rising need for surgical and anesthesia care. Infrastructure, medical personnel, service delivery, financing and protection are mandatory in order to achieve global surgery. These programs, along with research and professional training, should be grounded in LMICs and coordinated with high-income countries in a global network.