Evolution of global surgery: lessons learned and a look toward the future

Summary

Global surgery is focused on providing high-quality, sustainable surgical care to all people of the world. Over time, the emphasis has shifted from brief mission trips to collaborative partnerships and sustainable training programs that provide continuous access to surgical care. The evolution and future direction of global surgery were discussed by experts in the field at the 2024 Annual Point/Counterpoint Acute Care Surgery Conference in Baltimore, Maryland, on May 2, 2024. The following article summarizes each of the experts’ presentations and is followed by a summary of the evidence.

Introduction

Globally, it is estimated that five billion people do not have access to safe and life-saving surgical care.¹ Prior to 2013, global health efforts were heavily focused on treating infectious diseases and other nonsurgical ailments. The idea of bringing surgery and anesthetic care to remote regions of the world seemed too costly and burdensome. In 2010, the Global Burden of Disease study revealed that surgically treatable ailments made up a growing proportion of treatable disease.² In 2013, Dr Jim Kim, the President of the World Bank at the time, challenged the first Lancet Commission on Global Surgery to make the treatment of surgical disease a cornerstone of global health.³

Although the following years attempted to achieve this aim, many lessons have been learned along the way. Global surgery largely contains two categories: short stays that provide surgical care to as many patients as possible for typically 2 to 3 weeks at a time, and long-term training models that build sustainable infrastructure and programs around a region. The first method, often called ‘parachute mission trips’, is ideal for environments in immediate need, such as conflict zones, or diseases that generally have quick recovery periods and short-term follow-up, such as cleft lip and palates. The overarching goal of global surgery in the modern era, however, has transitioned towards a second method, creating a more sustainable impact in a region. This involves creating training programs, ensuring community engagement, and identifying local surgical and medical leaders in the field.

The field of global surgery is growing and changing rapidly. For those who have an interest, it is important to remain at the forefront of these changes. The 2024 Annual Point/Counterpoint Conference enlisted four experts in the field to discuss their experiences with and insight into the field of global surgery.

Introduction to global health (abridged summary)

Mayur Narayan, MD, MPH, MBA, MHPE, FACS, FCCM, FICS, FAIM, MAMSE, Professor of Surgery, Rutgers University, Robert Wood Johnson Medical School

There is an intrinsic internal conflict in global surgery. The desire to do good is balanced by the pressures of the bottomline for the institution and its return on investment. Often those driven into the field have a personal story that motivates them to sacrifice some of these bottom-line pressures.

Each aspect of the trauma chain of survival can be employed to make a large-scale global health impact. This involves injury prevention, bystander training, prehospital care, rehabilitation, and reintegration. To make changes in each of these areas, it is important to understand the local environment and the infrastructure available. The same models may not be applicable in different settings.

One method of creating a large-scale and far-reaching impact is to train people who will then go to other regions of the world and employ some of the teachings they received in a way that is implementable and scalable in their own communities. One such example is the creation of India’s first air ambulance system, which was brought to the country by local medical providers who spent time training in the USAand learning its emergency medical evacuation system.

Other methods of creating change are to partner with local organizations to help them achieve the goals applicable to their region. For example, the SaveLife Foundation (SLF) is a non-governmental organization (NGO) that has made incredible strides in promoting traffic safety in India. Through their work, India has seen a60%reduction in motor vehicle-related mortality. SLF also successfully advocated to pass a Good Samaritan Law in India, giving legal and procedural protection to bystanders who help victims of road crashes. Rutgers, Robert Wood Johnson Medical School, is helping this organization implement their ownEmergency Medical Treatment and Labor Act(EMTALA) amendment to the Indian constitution, which has the potential to impact all1.4 billionpeople in India. This sharing of knowledge and experiences is global surgery at work.

History of global health (abridged summary)

Daniel Whitley, MD, Assistant Professor of Surgery, Rutgers University, Robert Wood Johnson Medical School

The 2015 Lancet Commission on Global Surgery 2030 defined global surgery as an ‘area of study, research, practice 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’.⁴Global surgery is an evolution of the field of surgery, with a recent gain in momentum as more people are acknowledging that a majority of the world’s population does not have access to safe surgery, obstetrics, and anesthesia. 90% of surgical resources are consumed by the most privileged 10% of the world’s population and, on the contrary, 90% of trauma mortality occurs in low- and middle-income countries.⁵

The history of global surgery begins as far back as DrWilliam Halsted,who traveled to Europe to learn from the established surgical giants of the time. DrHalsted not only brought back the clinical knowledge he learnedbut also established, based on the European model, the concept of the surgical residency that we know and understand today. This sharing of information and training models is the basis of global surgery. There are several examples of trainees going abroad to learn practices and protocols to bring back to their own country.

In 1978, the Alma Ata Declaration adopted primary healthcare as a means for providing universal equitable services for all countries, which was unanimously adopted by all WHO countries. Two years later, Dr Halfdan Mahler, the Director General of the WHO, incorporated the ideals of the Alma Ata Declaration but also linked public health, primary care, and surgery with those goals.⁶He proposed creating a list of essential surgical procedures that every first aid healthcare worker and general surgeon should be able to provide. The goals outlined in the Alma Ata and beyond were meant to be achieved by the year 2000, but unfortunately, millions of people were still lacking care. In 2008, Dr Paul Farmer and Dr Jim Kim described surgery as the neglected stepchild of global public health and outlined their vision that key surgical services should always be available in the public sector.⁷The 2010 global burden of surgical disease study showed a significant shift in the burden of disease toward noncommunicable surgical diseases, such as trauma, as a major burden worldwide.²

Using disability-adjusted life years, providing surgical care has been proven to be extremely cost-effective. In fact, the cost of not investing in surgery is estimated to cost about 12 trillion dollars in the global economy, with an estimated US$20.7 trillion loss to the global economy by 2030.⁸In 2012, at the Copenhagen Consensus, a panel of economists stated that strengthening surgical capacity is one of the most cost-effective investments in the world.⁹

Surgical education and global health (abridged summary)

Mary Ann Hopkins, MD, Associate Professor of Surgery, New York University

108.4 million people were displaced in 2022, this is up from 40 million in the early 2000s.¹⁰To make matters worse, the countries that are receiving most of the displaced people are low- or middle-income countries and their economy and healthcare systems are becoming increasingly stressed by the added populations.

The poorest countries also have the fewest physicians.To incentivize the development of healthcare systems, the UNdeveloped theMillennium Development Goals(MDGs) and tied the achievement of these goals to the administration of funds through the World Bank. However, none of the goals addressed access to surgical care. Following that, the Sustainable Development Goals, which finally recognized the need for universal access to essential surgical care, replaced the MDGs. This was the first time that the goal of providing safe and quality surgical care was tied to financial investments into a country.

The poorest 35% of the world only account for 3.5% of the surgeries undertaken worldwide.⁴The cost of increasing access to surgery is about 300 billion dollars.¹¹However, not investing in this surgical access is estimated to cost the worldwide economy more than 12 trillion dollars.

Education is the key to sustainable global surgical development. The brain drain is a significant issue facing many low-income and conflict-ridden countries. More than50%of trained medical providers from northern Africa are not working in the countries in which they were trained. Additionally, simple educational tools can be created to educate students and trainees around the world. WISE-MD was a web-based application designed to give students around the world access to teaching modules. Through this application, students can learn how to suture even if access to large-scale teaching institutions or surgical programs are lacking in their region. This sharing of knowledge is the future of creating sustainable global surgicalimpact.Finally, the most important thingevery surgeon can do for global surgery, particularly those in leadership positions, is to support their students, trainees, and faculty in their interests to pursue global surgery.

Going beyond trips: academic and educational avenues in global surgery (abridged summary)

Ziad Sifri, MD, Professor of Surgery, Rutgers University, New Jersey Medical School

Research is an important aspect of global surgical interest. Dr Sifri and his colleagues have completed several research studies focused on the impact of global emergency surgery on patients and their families, the prevalence of interest in global surgery in American medical students and residents, and the impact of experiences as a trainee on choosing a career that includes global surgery.12,17

Their group conducted a survey of 97 fourth-year medical students applying to a single general surgery program in New Jersey from 2019 to 2020. Among those surveyed, 50% of students reported that they would rank a residency program higher if there is an avenue for global surgical interests.¹³Rutgers, New Jersey Medical School, has found success in attracting research fellowship applicants by creating a fellowship track dedicated to global surgery and global health. The fellows accepted into this track spend a year doing a combination of surgical trips, global surgery research, and getting degrees and certificates applicable to a career in global surgery.

There are several challenges to conducting research in low- and middle-income countries. Some pitfalls include the ethical issues related to collaboration and obtaining informed consent.¹⁸Many countries do not have the same infrastructure as the USA in ensuring the protection of research subjects, and the onus falls on the investigator to maintain high standards. In addition, collaboration is difficult because of the contingencies that are often tied to financial aid, which can create distrustful relationships between the local population and researchers. Buy-in from all participating parties, however, is critical to a project’s success.

The largest barrier to conducting high-quality outcome research may be inadequate follow-up, particularly in short-term missions. The best way to create sustainable follow-up is to develop a community-based approach based on key barriers identified by all stakeholders. This is exemplified by the work of the global surgery team at Rutgers. They created a ‘follow-up bundle’ that was implemented by a core team of individuals that stayed for an additional week beyond the duration of the surgical mission trip. The bundle included making patients aware at the time of triage of the importance of follow-up, engaging community members and leaders, establishing an accessible location for follow-up, and reinforcing that information at the time of discharge. Using these new community-based bundle methods, they demonstrated an increase in the postoperative follow-up rate from 5% to 97%.¹²

Despite little resources, with a lot of passion, global surgery can lend itself to research, teaching, and innovation

Evidence summary

More than 5 billion people, about 63% of the world’s population, are without access to life-saving surgical treatment.¹ Dr Mahler, the former Director General of the WHO, acknowledged access to essential surgical care as a vital need for the first time in 1980 when, in his address to the World Congress of the International College of Surgeons, he identified that the majority of the world’s population did not have access to a skilled surgeon. He stated, ‘I beg of you to give serious consideration to this serious manifestation of social inequity in health care’.⁶ Unfortunately, little was done for several years. The global health community viewed surgery as a high-resource, high-cost endeavor that could not be scaled to meet the needs of low- and middle-income countries. The tide began to shift with the creation of the Lancet Commission on Global Surgery. In 2014, Dr Jim Kim addressed the first assembly and challenged everyone in the room to ‘build a shared vision and strategy for global equity in essential surgical care’.³ This time, there was enough groundwork and motivation to take on this challenge by those in the audience.

In 2015, the Lancet Commission on Global Surgery 2030 was published.⁴ They identified six goals and markers for safe surgical care to be achieved by the year 2030. Those included the following: (1) 80% access to essential surgical procedures per country; (2) 20 surgical, anesthetic, and obstetric physicians per 100 000 persons in all countries; (3) tracing surgical volume targeting a minimum of 5000 procedures per 100 000 persons; (4) tracking perioperative mortality; (5) protection against impoverishment from out-of-pocket payments; and (6) protection against catastrophic expenditure.

Although the world is far from achieving these goals, there are several reforms and initiatives that are ongoing in various regions around the world. There has been a focus on building the surgical capacity for first-level (ie, local/regional) hospitals to perform essential surgical care, particularly in the realm of trauma. In addition, creating a pipeline of first-level to second-level or third-level hospitals would expedite referrals and promote a triage system for those who may need higher level care. Since the establishment of the Lancet Commission, efforts have been made to integrate these programs into national health plans by creating the National Surgical Obstetrics and Anesthesia Plans (NSOAPs). The WHO has now mandated that all countries report their NSOAP progress every 2 years. Several countries, such as Nigeria, Ethiopia, Tanzania, and Zambia, have attempted to implement this nationalized initiative.

The ideal approach is to target resources based on evidence-based regional needs. Studying the most cost-effective procedures and the effects of any regional programs typically requires the infrastructure of a large academic medical center. The areas in greatest need, however, often lack academic centers. Combating this problem will require partnerships between high-income countries with large academic centers and low- and middle-income countries to create more academic productivity and visibility in global surgery.

The main argument against redirecting global health efforts toward surgery over infectious diseases, for instance, has been the cost. However, the authors of a systematic review showed that a majority of high-priority procedures are more cost-effective, with respect to cost per disability-adjusted life years compared with anti-malarial efforts, vaccines, and treatment for heart disease or HIV.¹⁹ A subsequent study calculated how much money would be required to scale up these surgical interventions to achieve the Lancet Commission goals by 2030. The authors estimated that the total cost would be around US$300 to US$420 billion from 2012 to 2030.¹¹ They argued that to achieve the goals stated in the Lancet Commission, more funding would have to be given to these countries and initiatives.

Despite the large strides still needed to achieve global surgical equity, there are several things we can do as individuals and organization to help. One option is to enlist in short-term mission trips in conflict zones that are suffering from a rapid rise in medical and surgical needs that are overwhelming the current infrastructure (ie, Médecins Sans Frontières). It is important to recognize that safety cannot always be assured in these environments and these realities should be carefully discussed with loved ones prior to embarking on such an endeavor. Other options closer to home are to continue supporting faculty, students, and trainees interested in pursuing global surgery and health. This may require clinical flexibility, funding, and buy-in from all hospital stakeholders. Additionally, leveraging technology such as telemedicine, remote skills training, and most recently, artificial intelligence, will all need to be utilized to help bridge the gap of surgical equity. Finally, creating knowledge-sharing initiatives is one of the most effective ways of creating sustainable change and training models.

Conclusions

Global surgery has transitioned from the ‘forgotten stepchild’ to a critical component of every global health initiative. The Lancet Commission for Global Surgery 2030 has outlined ambitious goals to be achieved by the year 2030. Although there is still much work to be done, there are several ways for every surgeon to get involved and support the initiative to bring safe and efficient surgical care to every person in the world.