Andrew J M Leather

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anesthesia care in low- and middleincome countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labor, congenital anomalies, and breast and cervical cancer. Although the term, low- and middleincome countries (LMICs), has been used throughout the report for brevity, the Commission realizes that tremendous income diversity exists between and within this group of countries. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, noncommunicable diseases, and injuries. Surgical and anesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anesthesiacare,whichshouldbeavailable, affordable,timely,andsafetoensuregood coverage, uptake, and outcomes. Despite a growing need, the develop

Global cancer surgery: delivering safe, affordable, and timely cancer surgery

Surgery is essential for global cancer care in all resource settings. Of the 15.2 million new cases of cancer in 2015, over 80% of cases will need surgery, some several times. By 2030, we estimate that annually 45 million surgical procedures will be needed worldwide. Yet, less than 25% of patients with cancer worldwide actually get safe, affordable, or timely surgery. This Commission on global cancer surgery, building on Global Surgery 2030, has examined the state of global cancer surgery through an analysis of the burden of surgical disease and breadth of cancer surgery, economics and financing, factors for strengthening surgical systems for cancer with multiple-country studies, the research agenda, and the political factors that frame policy making in this area. We found wide equity and economic gaps in global cancer surgery. Many patients throughout the world do not have access to cancer surgery, and the failure to train more cancer surgeons and strengthen systems could result in as much as US

Surgery and global health: a Lancet Commission

6.2 trillion in lost cumulative gross domestic product by 2030. Many of the key adjunct treatment modalities for cancer surgery--e.g., pathology and imaging--are also inadequate. Our analysis identified substantial issues, but also highlights solutions and innovations. Issues of access, a paucity of investment in public surgical systems, low investment in research, and training and education gaps are remarkably widespread. Solutions include better regulated public systems, international partnerships, super-centralisation of surgical services, novel surgical clinical trials, and new approaches to improve quality and scale up cancer surgical systems through education and training. Our key messages are directed at many global stakeholders, but the central message is that to deliver safe, affordable, and timely cancer surgery to all, surgery must be at the heart of global and national cancer control planning.

Clinical features of patients isolated for suspected Ebola virus disease at Connaught Hospital, Freetown, Sierra Leone: a retrospective cohort study

Delivery of surgical care—defi ned here as surgery, anaesthesia, nursing, and work by allied health pro fessionals, including managers—plays a fundamental part in prevention, diagnosis, treatment, and palliation of a broad range of medical disorders (fi gure), and is a crucial component of a properly functioning health-care system and a prerequisite for universal health coverage. Today, an estimated two billion people worldwide are without adequate access to surgical care, and a substantial global gap exists between surgical need and the equitable provision of safe surgical care. Low-income and middleincome countries have the greatest burden of untreated surgical disease; addressing this inequity—borne largely by low-income populations—is a moral imperative for the so-called reimagining of global surgery. In addition to the moral imperative, there are also strong economic reasons to prioritise surgery. The untreated surgical disease burden translates into great economic strain on local and regional economies. However, despite the cost-eff ectiveness of providing surgical interventions in resource-constrained environ ments, there is a perceived absence of political priority both nationally and globally, and a paucity of policy support and scalable solutions for development of functional surgical systems in low-income and middle-income countries. Surgery has now reached a crucial juncture in global health. A Lancet Commission on Global Surgery is timely. A commission is needed to acknowledge surgical care delivery as a core component of health systems, and to embed surgical care within present global health initiatives and the post-2015 global health agenda. The Lancet Commission on Global Surgery will engage experts across the global health community to defi ne the best strategies for provision of surgical care with a focus on low-income and middle-income health systems, while also recognising the major issues related to equitable delivery of high-quality surgical care in areas of confl ict, disaster, and in high-income settings. The Commission will provide advocacy for defi nitive action and an impetus for implementation of surgical health system reform. The commissioners include clinicians, scientists, educators, and policy leaders in multiple and allied health specialties related to surgical care delivery from around the world. The Commission will have three cochairs leading the process (John G Meara, Andrew J M Leather, and Lars Hagander) who will also call on a group of international advisers to provide specifi c content expertise for the many diff erent aspects of the Commission’s remit. The process will be open and consultative, incorporating advice and input from all stakeholders involved in providing, funding, or governing surgical care. Seven of the initial commissioners began the planning process during the spring of 2013. After preparatory meetings in Boston, London, and Lund, and multiple teleconferences, the Commission on Global Surgery will formally launch on Jan 17–18, 2014, in Boston. The fi rst meeting will convene more than 80 people including commissioners, advisers, and global health leaders from around the world. Additionally, it will have representatives from previous commissions and other global health initiatives to generate a unifi ed force for change. After the Boston meeting, two subsequent meetings will be held in Sierra Leone in May, and at a venue yet to be decided in September. The Commission will begin by examining the present state of surgery within the global health agenda and will then characterise the role, nature, and range of surgery within health systems. This initial investigation will build on the growing body of global surgery literature, and will be coordinated by four working groups concentrating on care delivery, workforce, information, and fi nance. Leadership and governance 11 CenterWatch. The Medicines Company, Alnylam develop RNAi therapeutics for hypercholesterolemia. CenterWatch News Online Feb 4, 2013. http:// www.centerwatch.com/news-online/article/4393/the-medicinescompany-alnylam-develop-rnai-therapeutics-for-hypercholesterolemia (accessed Sept 6, 2013). 12 Giugliano RP, Desai NR, Kohli P, et al. Effi cacy, safety, and tolerability of a monoclonal antibody to proprotein convertase subtilisin/kexin type 9 in combination with a statin in patients with hypercholesterolaemia (LAPLACE-TIMI 57): a randomised, placebo-controlled, dose-ranging, phase 2 study. Lancet 2012; 380: 2007–17. 13 Stein EA, Gipe D, Bergeron J, et al. Eff ect of a monoclonal antibody to PCSK9, REGN727/SAR236553, to reduce low-density lipoprotein cholesterol in patients with heterozygous familial hypercholesterolaemia on stable statin dose with or without ezetimibe therapy: a phase 2 randomised controlled trial. Lancet 2012; 380: 29–36. 14 Stein EA, Mellis S, Yancopoulos GD, et al. Eff ect of a monoclonal antibody to PCSK9 on LDL cholesterol. N Engl J Med 2012; 366: 1108–18.

Global surgery: defining an emerging global health field

BACKGROUND The size of the west African Ebola virus disease outbreak led to the urgent establishment of Ebola holding unit facilities for isolation and diagnostic testing of patients with suspected Ebola virus disease. Following the onset of the outbreak in Sierra Leone, patients presenting to Connaught Hospital in Freetown were screened for suspected Ebola virus disease on arrival and, if necessary, were admitted to the on-site Ebola holding unit. Since demand for beds in this unit greatly exceeded capacity, we aimed to improve the selection of patients with suspected Ebola virus disease for admission by identifying presenting clinical characteristics that were predictive of a confirmed diagnosis. METHODS In this retrospective cohort study, we recorded the presenting clinical characteristics of suspected Ebola virus disease cases admitted to Connaught Hospitals Ebola holding unit. Patients were subsequently classified as confirmed Ebola virus disease cases or non-cases according to the result of Ebola virus reverse-transcriptase PCR (EBOV RT-PCR) testing. The sensitivity, specificity, positive predictive value, negative predictive value, and likelihood ratio of every clinical characteristic were calculated, to estimate the diagnostic accuracy and predictive value of each clinical characteristic for confirmed Ebola virus disease. RESULTS Between May 29, 2014, and Dec 8, 2014, 850 patients with suspected Ebola virus disease were admitted to the holding unit, of whom 724 had an EBOV RT-PCR result recorded and were included in the analysis. In 464 (64%) of these patients, a diagnosis of Ebola virus disease was confirmed. Fever or history of fever (n=599, 83%), intense fatigue or weakness (n=495, 68%), vomiting or nausea (n=365, 50%), and diarrhoea (n=294, 41%) were the most common presenting symptoms in suspected cases. Presentation with intense fatigue, confusion, conjunctivitis, hiccups, diarrhea, or vomiting was associated with increased likelihood of confirmed Ebola virus disease. Three or more of these symptoms in combination increased the probability of Ebola virus disease by 3·2-fold (95% CI 2·3-4·4), but the sensitivity of this strategy for Ebola virus disease diagnosis was low. In a subgroup analysis, 15 (9%) of 161 confirmed Ebola virus disease cases reported neither a history of fever nor a risk factor for Ebola virus disease exposure. INTERPRETATION Discrimination of Ebola virus disease cases from patients without the disease is a major challenge in an outbreak and needs rapid diagnostic testing. Suspected Ebola virus disease case definitions that rely on history of fever and risk factors for Ebola virus disease exposure do not have sufficient sensitivity to identify all cases of the disease. FUNDING None.

Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development

Global health is one of the defi ning issues of the 21st century, attracting unprecedented levels of interest and propelling health and disease from a biomedical process to a social, economic, political, and environmental concern. Surgery, however, has not been considered an integral component of global health and has remained largely absent from the discipline’s discourse. After much inattention, surgery is now gaining recognition as a legitimate component of global health. In January, 2014, Jim Kim, President of the World Bank, urged the global health community to challenge the injustice of global inequity in surgical care, stating that “surgery is an indivisible, indispensable part of health care and of progress towards universal health coverage”. However, defi ning a place for surgery within the current global health paradigm of disease-based care and issue-specifi c advocacy remains a challenge—surgery is not a distinct disease entity such as HIV/AIDS, nor does it target a specifi c demographic such as reproductive, maternal, neonatal, and child health. Rather, surgery plays a part in addressing a diverse set of cross-cutting health challenges within a health system and is crucial to the full attainment of global health goals. Individuals and groups committed to addressing global inequity in access to surgery and improving the status of surgical care within global health have started to come together under the umbrella of global surgery. Although the term global surgery has rapidly entered the vernacular, a defi nition has not been provided. Here, we discuss the importance of defi ning global surgery to advance its role as an indivisible component of global health and propose a working defi nition that can serve as a focal point around which both the surgical and wider global health community can unite. Increased awareness of the place for surgery within global health will benefi t not only the surgical community, but all those working to improve health outcomes, strengthen health systems, and reduce health inequities at a local and global scale. Common defi nitions in global health are central to the setting of objectives, priorities, and strategies, communication of goals and vision, and channelling of resources. They can also act as a rallying point, to unify diff erent actors and create strong community cohesion, which is key to generation of political priority. The nascent global surgery movement would do well to learn from global health’s mistakes. Failure to defi ne global health early in its own development allowed and even encouraged several, competing, and sometimes contradictory frames of reference to emerge. The confusion was damaging and created silos and factions among groups instead of cohesion and cooperation. Although global surgery has not been defi ned formally, defi nitions for various related terms including surgical care, surgical conditions, and surgical providers have been proposed (appendix). These defi nitions take a broad, inclusive approach to the defi nition of surgery, recognising that surgical care is usually delivered within multidisciplinary teams. Such care does not always involve an operation or procedure and can be delivered at primary care level and in the hospital setting. Underpinning the emergence of the term global surgery has been a desire to link surgical need with the overall global health agenda. To defi ne global surgery conceptually, the central tenets of global health therefore need to be incorporated. These tenets have themselves been the subject of much analysis and debate, but are broadly considered to include the global conceptualisation of health, the synthesis of population-based approaches with individual level clinical care, the central concept of equity in health, and the cross-sectoral, interdisciplinary approach to the understanding of ill health and its solutions. The term global in global health refers to health issues that are worldwide or universally present, that transcend national boundaries, and are supraterritorial—such as, for example, climate change. The key commonality is that global is used to refer to the scope of the problems not their physical location. So too for global surgery. In the absence of a clear defi nition, global surgery has been increasingly used to refer to surgery within geographical boundaries, and particularly within low-income and middle-income countries. A focus on these countries is appropriate because inequity is greatest in these regions. However, defi nition of the specialty as referring only to the problems of specifi c countries or regions would be incorrect. Concentration on the scope of the problems and the processes driving them rather than the geographical boundaries in which they are contained allows for greater insight into determinants and solutions. A global approach to surgery will mean a change in the way responsibility and accountability for surgical care are approached. Because the causes of inadequate or inequitable surgical care and the solutions are often interconnected or interdependent, the burden and responsibility for improving care is collective and needs to extend beyond sovereign borders. Identifi cation of successful strategies for increasing collective responsibility, action, and accountability at a global level, which are also locally grounded, will be crucial to meaningful progress in global surgery. The emergence of several transnational initiatives that address globally relevant issues in surgery such as patient safety, hospitalacquired infection, and international organ traffi cking are examples of strategies that have been conceived at a global level, developed on the basis of collective responsibility, and adopted within countries and local institutions. Published Online May 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60237-3

Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development

John G Meara*, Andrew J M Leather*, Lars Hagander*, Blake C Alkire, Nivaldo Alonso, Emmanuel A Ameh, Stephen W Bickler, Lesong Conteh, Anna J Dare, Justine Davies, Eunice Dérivois Mérisier, Shenaaz El-Halabi, Paul E Farmer, Atul Gawande, Rowan Gillies, Sarah L M Greenberg, Caris E Grimes, Russell L Gruen, Edna Adan Ismail, Thaim Buya Kamara, Chris Lavy, Ganbold Lundeg, Nyengo C Mkandawire, Nakul P Raykar, Johanna N Riesel, Edgar Rodas‡, John Rose, Nobhojit Roy, Mark G Shrime, Richard Sullivan, Stéphane Verguet, David Watters, Thomas G Weiser, Iain H Wilson, Gavin Yamey, Winnie Yip

Global Surgery 2030: a roadmap for high income country actors

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries (LMICs) has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer. In 2015, many LMICs are facing a multifaceted burden of infectious disease, maternal disease, neonatal disease, non-communicable diseases, and injuries. Surgical and anaesthesia care are essential for the treatment of many of these conditions and represent an integral component of a functional, responsive, and resilient health system. In view of the large projected increase in the incidence of cancer, road traffic injuries, and cardiovascular and metabolic diseases in LMICs, the need for surgical services in these regions will continue to rise substantially from now until 2030. Reduction of death and disability hinges on access to surgical and anaesthesia care, which should be available, affordable, timely, and safe to ensure good coverage, uptake, and outcomes. Despite growing need, the development and delivery of surgical and anaesthesia care in LMICs has been nearly absent from the global health discourse. Little has been written about the human and economic effect of surgical conditions, the state of surgical care, or the potential strategies for scale-up of surgical services in LMICs. To begin to address these crucial gaps in knowledge, policy, and action, the Lancet Commission on Global Surgery was launched in January, 2014. The Commission brought together an international, multi- disciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents. We formed four working groups that focused on thedomains of health-care delivery and management; work-force, training, and education; economics and finance; and information management. Our Commission has five key messages, a set of indicators and recommendations to improve access to safe, affordable surgical and anaesthesia care in LMICs, and a template for a national surgical plan.

International Health Links movement expands in the United Kingdom

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the worlds new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future.

Diffusion of e-health innovations in 'post-conflict' settings: a qualitative study on the personal experiences of health workers

The need to strengthen health capacity in developing countries is widely documented. The World Health Organization has called for an increase in the number of health workers in all countries experiencing critical shortages, a significant scaling-up of training and more efficient use of existing health workers. Health Links, long-term mutually beneficial partnerships between UK health institutions and their counterparts in developing countries, are helping to fill these gaps. Links allow for the reciprocal transfer of knowledge and skills between partners, enabling the UKs expertise in health service delivery and training to be channelled towards the needs of those in developing countries, while also bringing a wide range of benefits to the UK. Examples of Health Links in Ethiopia demonstrate such benefits. An increasingly supportive policy environment is enabling a significant expansion in the number of Links. However, the quality of these Links is critical to their impact and thus there is a need both to continue to support those engaging in Links to develop sustainable, mutually beneficial strategic partnerships, and to strengthen the body of evidence of their impacts.