Stephen W. Bickler

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 access to surgical care: a modelling study

BACKGROUND More than 2 billion people are unable to receive surgical care based on operating theatre density alone. The vision of the Lancet Commission on Global Surgery is universal access to safe, affordable surgical and anaesthesia care when needed. We aimed to estimate the number of individuals worldwide without access to surgical services as defined by the Commissions vision. METHODS We modelled access to surgical services in 196 countries with respect to four dimensions: timeliness, surgical capacity, safety, and affordability. We built a chance tree for each country to model the probability of surgical access with respect to each dimension, and from this we constructed a statistical model to estimate the proportion of the population in each country that does not have access to surgical services. We accounted for uncertainty with one-way sensitivity analyses, multiple imputation for missing data, and probabilistic sensitivity analysis. FINDINGS At least 4·8 billion people (95% posterior credible interval 4·6-5·0 [67%, 64-70]) of the worlds population do not have access to surgery. The proportion of the population without access varied widely when stratified by epidemiological region: greater than 95% of the population in south Asia and central, eastern, and western sub-Saharan Africa do not have access to care, whereas less than 5% of the population in Australasia, high-income North America, and western Europe lack access. INTERPRETATION Most of the worlds population does not have access to surgical care, and access is inequitably distributed. The near absence of access in many low-income and middle-income countries represents a crisis, and as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all. FUNDING None.

The treatment of paediatric burns using topical papaya

Due to the limited resources for the management of burns in most regions of Africa there is a significant role for many aspects of traditional African medicine. The active component of many traditional preparations is often of plant origin and more than 25 plants have been described as useful in relations to burns and wound healing. Carica papaya is currently used in The Gambia at the Royal Victoria Hospital, Banjul in the Paediatric Unit as the major component of burns dressings, where it is well tolerated by the children. Cheap and widely available, the pulp of the papaya fruit is mashed and applied daily to full thickness and infected burns. It appears to be effective in desloughing necrotic tissue, preventing burn wound infection, and providing a granulating wound suitable for the application of a split thickness skin graft. Possible mechanisms of action include the activity of proteolytic enzymes chymopapain and papain, as well as an antimicrobial activity, although further studies are required.

Key Concepts for Estimating the Burden of Surgical Conditions and the Unmet Need for Surgical Care

BackgroundSurgical care is emerging as a crucial issue in global public health. Methodology is needed to assess the impact of surgical care from a public health perspective.Method sA consensus opinion of a group of surgeons, anesthesiologists, and public health experts was established regarding the methodology for estimating the burden of surgical conditions and the unmet need for surgical care.Result sFor purposes of analysis, we define surgical conditions as any disease state requiring the expertise of a surgically trained provider. Abnormalities resulting from a surgical condition or its treatment are termed surgical sequelae. Surgical care is defined as any measure that reduces the rates of physical disability or premature death associated with a surgical condition. To measure the burden of surgical conditions and unmet need for surgical care we propose using cumulative disability-adjusted life-year (DALY) curves generated from age-specific population-based data. This conceptual framework is based on the premise that surgically associated disability and death is determined by the incidence of surgical conditions and the quantity and quality of surgical care. The burden of surgical conditions is defined as the total disability and premature deaths that would occur in a population should there be no surgical care; the unmet need for surgical care is defined as the potentially treatable disability and premature deaths due to surgical conditions. Burden of surgical conditions should be expressed as DALYs and unmet need as potential DALYs avertable.ConclusionsMethodology is described for estimating the burden of surgical conditions and unmet need for surgical care. Using this approach it will be feasible to estimate the global burden of surgical conditions and help clarify where surgery fits among other global health priorities. These methods need to be validated using population-based data.

Surgical services for children in developing countries

There is growing evidence that childhood surgical conditions, especially injuries, are common in developing countries and that poor care results in significant numbers of deaths and cases of disability. Unfortunately, however, surgical care is not considered an essential component of most child health programmes. Strategies for improving paediatric surgical care should be evidence-based and cost-effective and should aim to benefit the largest possible number of children. The most likely way of achieving policy change is to demonstrate that childhood surgical conditions are a significant public health problem. For paediatric purposes, special attention should also be given to defining a cost-effective package of surgical services, improving surgical care at the community level, and strengthening surgical education. Surgical care should be an essential component of child health programmes in developing countries.

Epidemiology of paediatric surgical admissions to a government referral hospital in the Gambia

INTRODUCTION There is a paucity of published data on the type of conditions that require surgery among children in sub-Saharan Africa. Such information is necessary for assessing the impact of such conditions on child health and for setting priorities to improve paediatric surgical care. METHODS Described in the article is a 29-month prospective study of all children aged < 15 years who were admitted to a government referral hospital in the Gambia from January 1996 to May 1998. RESULTS A total of 1726 children were admitted with surgical problems. Surgical patients accounted for 11.3% of paediatric admissions and 34,625 total inpatient days. The most common admission diagnoses were injuries (46.9%), congenital anomalies (24.3%), and infections requiring surgery (14.5%). The diagnoses that accounted for the greatest number of inpatient days were burns (18.8%), osteomyelitis (15.4%), fractures (12.7%), soft tissue injuries (3.9%), and head injuries (3.4%). Gambian children were rarely admitted for appendicitis and never admitted for hypertrophic pyloric stenosis. The leading causes of surgical deaths were burns, congenital anomalies, and injuries other than burns. DISCUSSION Prevention of childhood injuries and better trauma management, especially at the primary and secondary health care levels, should be the priorities for improving paediatric surgical care in sub-Saharan Africa. Surgical care of children should be considered an essential component of child health programmes in developing countries.

Estimated need for surgery worldwide based on prevalence of diseases: a modelling strategy for the WHO Global Health Estimate

BACKGROUND Surgery is a foundational component of health-care systems. However, previous efforts to integrate surgical services into global health initiatives do not reflect the scope of surgical need and many health systems do not provide essential interventions. We estimate the minimum global volume of surgical need to address prevalent diseases in 21 epidemiological regions from the Global Burden of Disease Study 2010 (GBD). METHODS Prevalence data were obtained from GBD 2010 and organised into 119 disease states according to the WHOs Global Health Estimate (GHE). These data, representing 187 countries, were then apportioned into the 21 GBD epidemiological regions. Using previously defined values for the incident need for surgery for each of the 119 GHE disease states, we calculate minimum global need for surgery based on the prevalence of each condition in each region. FINDINGS We estimate that at least 321·5 million surgical procedures would be needed to address the burden of disease for a global population of 6·9 billion in 2010. Minimum rates of surgical need vary across regions, ranging from 3383 operations per 100 000 in central Latin America to 6495 operations per 100 000 in western sub-Saharan Africa. Global surgical need also varied across subcategories of disease, ranging from 131 412 procedures for nutritional deficiencies to 45·8 million procedures for unintentional injuries. INTERPRETATION The estimated need for surgical procedures worldwide is large and addresses a broad spectrum of disease states. Surgical need varies between regions of the world according to disease prevalence and many countries do not meet the basic needs of their populations. These estimates could be useful for policy makers, funders, and ministries of health as they consider how to incorporate surgical capacity into health systems. FUNDING US National Institutes of Health.

Global surgery—defining a research agenda

In today’s Lancet, Thomas Weiser and colleagues report that there are 234 million major surgical procedures worldwide each year, one for every 25 people. This figure is more than twice the number of yearly births, and seven times the 33·2 million people infected with HIV. Because this estimate was based solely on major procedures, and did not include minor procedures or non-operative surgical care (eg, management of most blunt injuries), the actual surgical workload may be much higher. This massive volume of procedures, along with the attendant risks, clearly qualifies surgical diseases (any illness that Published Online June 25, 2008 DOI:10.1016/S01406736(08)60924-1

Developing Priorities for Addressing Surgical Conditions Globally: Furthering the Link Between Surgery and Public Health Policy

BackgroundEfforts to promote wider access to surgical services globally would be aided by developing consensus among clinicians, the public health policy community, and other stakeholders as to which surgical conditions warrant the most focused attention and investment. This would add value to other, ongoing efforts, especially in helping to define unmet need and effective coverage.MethodsIn this concept paper, we introduce preliminary ideas on how priorities for surgical care could be better defined, especially as regards the interface between the surgical and public health worlds. Factors that would come into play in this process include the public health burden of the condition and the successfulness and feasibility of the procedures to treat those conditions.Results and conclusionsThe implications of the prioritization process are that those conditions with the highest public health burden and that have procedures that are highly successful and feasible to promote globally, including in the most resource-constrained environments, should be the main focus of national and international efforts.

Improving Surgical Care in Low- and Middle-Income Countries: A Pivotal Role for the World Health Organization

In response to increasing evidence that surgical conditions are an important global public health problem, and data suggesting that essential surgical services can be delivered in a cost-effective manner in low- and middle-income countries, the World Health Organization (WHO) has expanded its interest in surgical care. In 2004, WHO established a Clinical Procedures Unit within the Department of Essential Health Technologies. This unit has developed the Emergency and Essential Surgical Project (EESC), which includes a basic surgical training program based on the “Integrated Management of Emergency and Essential Surgical Care” Toolkit and the textbook “Surgery at the District Hospital.” To promote the importance of emergency and essential surgical care, a Global Initiative for Emergency and Essential Care was launched in 2005. In what maybe the most important development, surgical care is included in WHO’s new comprehensive primary health care plan. Given these rapid developments, surgical care at WHO may be approaching a critical “tipping point.” Lobbying for a World Health Assembly resolution on emergency and essential surgical care, and developing “structured collaborations” between WHO and various stakeholders are potential ways to ensure that the global surgery agenda continues to move forward.