Hampus Holmer

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

Towards closing the gap of the global surgeon, anaesthesiologist, and obstetrician workforce: thresholds and projections towards 2030.

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.

The global met need for emergency obstetric care: a systematic review.

BACKGROUND Billions of people are without access to surgical care, in part because of the inequitable distribution of the surgical workforce. Drawing on recently collected data for the number of surgeons, anaesthesiologists, and obstetricians worldwide, we sought to show their global maldistribution by identifying thresholds of surgical workforce densities, and by calculating the number of additional providers needed to reach those thresholds. METHODS From the WHO Global Surgical Workforce Database, national data for the number of specialist surgeons, anaesthesiologists, and obstetricians per 100 000 population (density) were compared with the number of maternal deaths per 100 000 live births (maternal mortality ratio; MMR) in WHO member countries. A regression line was fit between density of specialist surgeons, anaesthesiologists, and obstetricians and the logarithm of MMR, and we explored the correlation for an upper and a lower density threshold. Based on previous estimates of the global volume of surgical procedures, a global average productivity per specialist was derived. We then multiplied the average productivity with the derived upper and lower threshold densities, and compared these numbers to previously estimated global need of surgical procedures (4664 procedures per 100 000 population). Finally, the numbers of additional providers needed to reach the thresholds in countries with a density below the respective threshold were calculated. FINDINGS Each 10-unit increase in density of surgeons, anaesthesiologists, and obstetricians, corresponded to a 13·1% decrease in MMR (95% CI 11·3-14·8). We saw particularly steep improvements in MMR from 0 to roughly 20 per 100 000 population. Above roughly 40 per 100 000 population, higher density was associated with relatively smaller improvements in MMR. These arbitrary thresholds of 20 and 40 specialists per 100 000 corresponded with a volume of surgery of 2917 and 5834 procedures per 100 000 population, respectively, and were symmetrically distributed around the estimated global need of 4664 surgical procedures per 100 000 population. Our density thresholds are slightly higher than the current average in lower-middle income countries (16 per 100 000) and upper-middle-income countries (38 per 100 000), respectively. To reach the threshold of at least 20 per 100 000 in each country today, another 440 231 (IQR 438 900-443 245) providers would be needed. To reach 40 per 100 000, 1 110 610 (IQR 1 095 376-1 183 525) providers would be needed. INTERPRETATION Assuming uniform productivity, a global surgical workforce between 20 and 40 per 100 000 would suffice to provide the worlds missing surgical procedures. We concede that causality cannot be implied, but our results suggest that countries with a workforce density above certain thresholds have better health outcomes. Although the thresholds cannot be interpreted as a minimum standard, they are useful to characterise the global surgical workforce and its deficits. Such thresholds could also be used as markers for health system capacity. FUNDING None.

International migration of surgeons, anaesthesiologists, and obstetricians.

Of the 287 000 maternal deaths every year, 99% happen in low‐ and middle‐income countries. The vast majority could be averted with timely access to appropriate emergency obstetric care (EmOC). The proportion of women with complications of pregnancy or childbirth who actually receive treatment is reported as ‘Met need for EmOC’.

Determining universal processes related to best outcome in emergency abdominal surgery: a multicentre, international, prospective cohort study.

www.thelancet.com/lancetgh Vol 3 (S2) April 2015 S11 The data provided by our study are relevant to both lower and higher income countries, and can help policy makers understand and predict the supply and demand of their future surgical workforce. For lower-income countries, addressing the shortage of surgical providers is fundamental to meeting the increasing need for surgical care. For higher-income countries that still depend on an influx of surgical professionals from lower-income countries, there should be much greater domestic capacity to meet the demand for surgeons, anaesthesiologists, and obstetricians. The internationally ratifi ed Global Code of Practice on the International Recruitment of Health Personnel aims to bring awareness in all countries to the importance of national workforce planning, resource allocation, and data collection. Although previous studies of international migration of physicians have used data from even fewer high-income countries, our study is limited by the inclusion of only 14 out of 75 high-income countries. This study is also limited by the fact that not all countries categorise specialists and subspecialists the same way, limiting comparisons between particular specialties. It is important to emphasise that the study results are based on the emigration of medical graduates, not necessarily fully trained specialists. Also, our study design did not address internal migration or the geographical maldistribution of the surgical workforce within countries due to migration into urban settings and to non-governmental organisations and administration, nor did we capture the surgical workforce migrating regionally between lowincome or middle-income countries. These limitations translate into a likely underestimation of the degree of migration out of the most severely affected settings, and we acknowledge that in analysing the surgical work force, one should also International migration of surgeons, anaesthesiologists, and obstetricians

Global health education in Swedish medical schools

Introduction Emergency abdominal surgery outcomes represent an internationally important marker of healthcare quality and capacity. In this study, a novel approach to investigating global surgical outcomes is proposed, involving collaborative methodology using ‘snapshot’ clinical data collection over a 2-week period. The primary aim is to identify internationally relevant, modifiable surgical practices (in terms of modifiable process, equipment and clinical management) associated with best care for emergency abdominal surgery. Methods and analysis This is a multicentre, international, prospective cohort study. Any hospital in the world performing acute surgery can participate, and any patient undergoing emergency intraperitoneal surgery is eligible to enter the study. Centres will collect observational data on patients for a 14-day period during a 5-month window and required data points will be limited to ensure practicality for collaborators collecting data. The primary outcome measure is the 24 h perioperative mortality, with 30-day perioperative mortality as a secondary outcome measure. During registration, participants will undertake a survey of available resources and capacity based on the WHO Tool for Situational Analysis. Ethics and dissemination The study will not affect clinical care and has therefore been classified as an audit by the South East Scotland Research Ethics Service in Edinburgh, Scotland. Baseline outcome measurement in relation to emergency abdominal surgery has not yet been undertaken at an international level and will provide a useful indicator of surgical capacity and the modifiable factors that influence this. This novel methodological approach will facilitate delivery of a multicentre study at a global level, in addition to building international audit and research capacity. Trial registration number The study has been registered with ClinicalTrials.gov (Identifier: NCT02179112).

Surgical Care: Addressing the Barriers to Access in Low-Income Countries

Aims: Global health education is increasingly acknowledged as an opportunity for medical schools to prepare future practitioners for the broad health challenges of our time. The purpose of this study was to describe the evolution of global health education in Swedish medical schools and to assess students’ perceived needs for such education. Methods:Data on global health education were collected from all medical faculties in Sweden for the years 2000–2013. In addition, 76% (439/577) of all Swedish medical students in their final semester answered a structured questionnaire. Results: Global health education is offered at four of Sweden’s seven medical schools, and most medical students have had no global health education. Medical students in their final semester consider themselves to lack knowledge and skills in areas such as the global burden of disease (51%), social determinants of health (52%), culture and health (60%), climate and health (62%), health promotion and disease prevention (66%), strategies for equal access to health care (69%) and global health care systems (72%). A significant association was found between self-assessed competence and the amount of global health education received (p<0.001). A majority of Swedish medical students (83%) wished to have more global health education added to the curriculum. Conclusions: Most Swedish medical students have had no global health education as part of their medical school curriculum. Expanded education in global health is sought after by medical students and could strengthen the professional development of future medical doctors in a wide range of topics important for practitioners in the global world of the twenty-first century.

The post-2015 development agenda: the role of surgical care in improving health.

We read with interest, in the October 2013 issue of World Journal of Surgery, the article by Samad et al. [1], which highlighted the barriers encountered by patients trying to access surgical care in a tertiary hospital in Pakistan. These challenges are ubiquitous across the health systems of many lowand middle-income countries [2]. Samad and colleagues identified some of the reasons that these barriers to accessing surgical care exist. They characterized the barriers as contributing to first-interval delay (from the onset of symptoms to seeking initial health care) and second-interval delay (from when surgery was first advised to when it was performed). Even when patients do access care, however, they may be lost to follow-up despite having developed potentially harmful postoperative complications [3]. Thus, there may be a ‘‘third interval’’ (time from surgery to follow-up) when factors exist that further complicate the patient’s experience of accessing care. Such adverse events may influence other patients not to seek care, thus adding to the important and potentially large group of patients who never receive care for surgical illness. With surgery previously identified as a necessary component of primary care to achieve universal health coverage [4], we applaud the authors’ call to integrate general practitioners (GPs) into a better surgical referral network and to improve their training to be able to make surgical diagnoses. This resounds well with the Declaration of Alma Ata on Primary Health Care [5], celebrating its 35th anniversary this year. Its message of an integrated health system with primary health care as the first point of contact for patients reiterates the need for outreach initiatives in the name of primary health care to increase equitable access to specialized health care services as well. GPs are also able to act as a conduit to help patients overcome barriers to seeking specialist care as well as to follow up and maintain long-term rehabilitation. The most prominent such barrier to surgical care described in this article was the lack of knowledge about disease implications and treatment options. Interestingly, such lack of knowledge was found to be the most likely factor hindering patients from initially seeking care. Additionally, we would argue that long-standing lack of access could have led patients to become less inclined to seek care. Samad and colleagues highlighted the role of poor literacy and faulty disease perceptions. They suggested initiating a focused education campaign to address these issues. As GPs were found to be the first point of contact for up to 80 % of the study population, their potential role in educating patients about their ailments, treatment options, and disease implications should be examined further. A well-informed population is more likely to seek care when it is needed and more inclined to comply with a proposed treatment. Financial constraints remain a challenge to individuals in many low-income countries. Efforts to decrease the costs involved in treatment (including follow-up)—e.g., transportation, lost earnings, diagnosis, treatment costs—are likely to potentiate any effort to increase access to health care for underserved populations. R. Ologunde (&) Faculty of Medicine, Imperial College London, South Kensington Campus, London SW7 2AZ, UK e-mail: rele.ologunde09@imperial.ac.uk

Letter from the future surgeons of 2030

During the past decade and a half, the global health landscape has been characterised by efforts to achieve the millennium development goals (MDGs). These eight health-related objectives agreed upon by the international health community were established in the millennium declaration. The formalisation of these goals and the predefined essential services needed to achieve them has garnered political priority and has been promoted through multiple institutions and organizations [1]. However, as the year 2015 approaches, and with it the target date to achieve the MDGs, attention is increasingly been drawn to the health architecture of the post-MDG era and the health priorities for this next chapter of international health promotion [2]. Key considerations include how to best place health in the post-2015 agenda. With a sizeable proportion of disease burden reducible by surgical intervention [3] coupled with the current inequitable distribution of surgical services globally [4], it is clear that surgical care should play an important role in improving health in the post-2015 era. The challenge of improving access to surgical care in many lowand middle-income countries (LMICs) is well documented in the literature [3]; barriers to care include insufficient accessibility, affordability, availability, and acceptability of care, compounded by a lack of an adequate surgical workforce [5]. Despite these challenges, improving access to surgical care has been shown to be a cost-effective and sustainable intervention that can have simultaneous and reciprocal benefits within a health system [3], and for society as a whole by promoting development through the enhancement of equity, improving economic status by limiting time spent out of work due to disability, and strengthening health systems. Achieving universal health coverage alone, in the 15 years following 2015, will not be enough to ensure that populations currently burdened with disease begin to experience improvements in health. Prevention programmes (for example to reduce road traffic accidents) and continued public health promotion and education accompanied by timely access to healthcare must be imperative to discussion on the post-2015 development agenda. To adequately comprehend the burden of surgical disease in LMICs and evaluate progress towards tackling it, there is a need to establish appropriate metrics to quantify the burden. The utility of relevant metrics will be evident in their ability to aid identification of areas for improvement in terms of operative and postoperative care, infrastructure, human resources, availability of surgical procedures, and essential surgical equipment. Such metrics can also aid in informing global health discourse on surgical care priority setting and advocacy to achieve sustained global awareness in the role of surgery as a post-MDG global health priority. In the year 2000, 189 countries adopted the millennium declaration and set international objectives, which have resulted in tangible gains in global health. In the year 2030, will we acknowledge that our post-MDG era achieved comparable improvements in global health, or will we lament a missed opportunity?

Global distribution of surgeons, anaesthesiologists, and obstetricians

1942 www.thelancet.com Vol 386 November 14, 2015 that mobility of students and trainees is fundamental, and denying some doctors the opportunity to learn from colleagues in richer countries—when the reverse is encouraged—is unjust. Instead, exchanges should be seen as an opportunity, and incentives for physicians to work in unfamiliar settings should be developed. Technology-related discussion was absent at the launch, and despite the digital revolution of this century, technology was not mentioned as a potential bridge between countries. Our international group has grown accustomed to collaborating using the internet, and we are adamant such benefits should not be overlooked. Better access to updated information and guidelines would be of huge benefit to students and surgeons worldwide. Finally, investment in future medical staff and systems is impossible without investment in students worldwide. Access to mentors and guidance, and research and practical opportunities are all paramount to training the next generation on the front line of global surgery in 2030.