Almost all Americans who rupture a spleen, develop a tumor, or need a caesarean section have easy access to a surgeon who can do what needs to be done to save their lives and get them back to normal life. That’s not the case in most parts of the world, where it’s difficult or impossible to have surgery when needed.
Nearly one-third of the global burden of disease — the collective impact of death and disability caused by all diseases around the world — can be chalked up to conditions that need surgery for treatment. Yet an estimated 5 billion people, more than two-thirds of the world’s population, don’t have reliable access to safe, effective, and affordable surgical and anesthetic care. That translates into millions of unnecessary deaths and untold disability every year.
We’ve seen this firsthand in our work in Rwanda, Haiti, and other parts of the world. We’ve also seen the difference that surgical care can make.
Take the case of Mukazitoni Marie (not her real name, to protect her privacy), a 60-year-old Rwandan woman. She began vomiting after meals and couldn’t keep food down. Despite seeing traditional healers and a clinician at a state-sponsored health post, she began to waste away. She was referred to the university teaching hospital in Kigali, the capital city. Her stomach was blocked by cancer, and she needed surgery. Because of the dearth of surgeons in the country, she was wait-listed for two months. Looking emaciated, she was sent home to wait, where she died a few days later of dehydration and starvation.
Two years later, 41-year-old Jean Paul (name protected again) came to the same hospital with almost the same health problems. He was diagnosed with stomach cancer. This time, the wait for surgery was only one week, thanks in large part to support from 25 US academic medical centers through the Rwanda Human Resources for Health program. Jean Paul underwent a complex operation in which 80 percent of his stomach was removed and the tumor was peeled from his pancreas and other nearby structures. The operation was performed by two Rwandan physicians in their final year of surgical training. They were supervised by a US-based surgeon through this training program, which helped prepare the Rwandan surgeons to perform this operation, and others like it, on their own in the future.
Expanding global access to surgery
Well-supplied surgical teams from the US and other developed countries regularly swoop into low-income countries for two or three weeks at a time, often earning glowing reports in the media with powerful before and after photos. Their efforts are commendable. But they won’t close the “surgery gap.” Once they leave, the country is no better equipped to care for people who need surgery than before the visit. Women still die from bleeding after giving birth. Young men still find themselves unable to work after their broken legs are never repaired. Children still bear disabling scars from untreated burns.
As part of an international group of clinicians, business leaders, policy experts, and health care advocates called the Lancet Commission on Global Surgery, we strongly believe that there are more effective, and, frankly, more ethical ways to do this. Writing in Wednesday’s inaugural issue of BMJ Global Health, this group lays out a road map for how high-income countries can help. It includes 50 recommendations for how medical schools, academic medical centers, surgical training programs, global health funders, industry, the press, and advocacy organizations can improve care for people who currently have little access to surgery.
First and foremost, initiatives to improve access to surgery must emerge from the needs identified by the host country. Without this essential input, a global surgery program may do little good and may actually cause harm. Global surgery programs must also be based on a true two-way partnership, equal collaboration, respect, and trust. For team members from high-income countries, a big dose of humility may also be indispensable.
Excellent programs to train more surgeons already exist. Examples include the Rwanda program described earlier; the partnership between the Royal College of Surgeons in Ireland and the College of Surgeons of East, Central, and Southern Africa; and the programs connecting the Royal Australasian College of Surgeons and the Fiji School of Medicine and others.
But these don’t come close to making up the shortfall of nearly 150 million surgeries each year in low- and middle-income countries. Many more stakeholders are needed to make access to effective, safe, and affordable surgical care a reality. For billions of people, that’s truly a matter of life and death.
Sarah L.M. Greenberg, MD, is a surgical resident at the Medical College of Wisconsin in Milwaukee, a former senior research fellow in the Harvard Medical School Program in Global Surgery and Social Change, and one of the lead authors of “Global Surgery 2030: a roadmap for high-income actors.” Robert Riviello, MD, is director of the Center for Surgery and Public Health’s global surgery programs at Brigham and Women’s Hospital and helped launch Harvard Medical School’s participation in the Human Resources for Health program in Rwanda.
