International surgery and the Canadian Journal of Surgery

Several years ago, the Canadian Journal of Surgery (CJS) initiated a section on international surgery. This decision was motivated by an understanding that CJS readers are interested in surgery in low-income countries and that the inclusion of articles about surgical care and research in low-income countries is part of the mandate of any truly international surgical journal.

What is the role of the CJS international surgery section? Consistent with the journal's overall mandate, it encourages the publication of high-quality original research and review articles. It differs from other parts of the journal in its focus on work performed in under-resourced environments within low-income countries. Mentorship is another objective of this section.¹ The content of the international articles should equal that of contributions in other sections, but editorial assistance to ensure that important contributions are not rejected because of writing skill or style is considered appropriate. Recently, the CJS editors were asked to post “Surgery in Africa,”² an electronic seminar, on the CJS website. The editorial board felt this was a reasonable request but that that “Surgery in Africa” must first be reviewed to assure the seminar's quality before it is posted. Maintaining standards increases the credibility of international surgery as a legitimate academic and clinical discipline.

Does a readership for this section exist within Canada? The Canadian Network for International Surgery,^3,4 the Office for International Surgery at the University of Toronto⁵ and the Canadian Association of General Surgeons Committee for International Surgery⁶ have been active for more than 10 years, with expanding Canadian membership, budgets and international activities. The Bethune Round Table on International Surgery, a well-attended annual meeting in Canada, has been growing in popularity and scientific rigour since its commencement 8 years ago.⁷ In 2005, a summary of the Bethune presentations was published in the CJS.⁸

Progress is being made. Published in this issue are the individual abstracts from the May 2008 Bethune Round Table. Initiated by the Office of International Surgery at the University of Toronto, “ownership” of this meeting has become national. For the first time, it was held outside Toronto, in Vancouver, and was hosted by the Branch for International Surgery at the University of British Columbia and the Canadian Network for International Surgery. It is expected that this represents the beginning of a national rotation. Surgeons from all the provinces and many participants from the United States, as well as participants from 10 low-income countries, attended.

By including a section on international surgery, the CJS is not the only Canadian surgical institution to formalize its international surgery mandate. Recently, the University of British Columbia, McGill University, the University of Calgary and the University of Ottawa have initiated at offices or branches of international surgery.⁹ Further, significant interest in international surgery also exists at both Memorial University and the University of Manitoba. A survey of Canadian surgical residents estimates that at least 24% intend to include international surgery as part of their future practice.¹⁰

The Canadian contribution to the global international surgery community is strong and increasing, and some Canadian initiatives are being replicated by surgeons in other high income countries. This global community comprises clinicians and academics from high-, middle-and low-income countries who work for nongovernmental organizations and universities. They are involved in the delivery of surgical, obstetric and anesthetic clinical and educational services to underresourced communities throughout the world. In addition to the extensive expertise and experience present in all countries, the organizations based in high-income countries have access to financial resources needed to improve surgical care.

Members of the international surgery community have no direct access to policy-makers and often have limited expertise in policy development. On the other hand, the World Health Organization (WHO) has policy expertise and, more important, direct access to policy-makers in countries with inadequate emergency and essential surgical care. The WHO has begun to set national standards¹¹ and is also taking the lead on issues of safe surgery.¹²

In late 2005, the Global Initiative for Emergency and Essential Surgical Care (GIEESC)¹³ was established in Geneva. The outcome of this and subsequent meetings, the most recent of which was held in September 2007 in Tanzania, is an initiative that formalizes the partnership between the WHO and recognized members from the international surgical community. This partnership will promote standards, research, safety and training in emergency and essential surgical care in low-and middle-income countries.¹³

In the 21st century, it is the practice to reject inappropriate surgical projects with high costs, low output and poor outcomes; at the same time, it is recognized that well-designed and cost-effective surgical programs are absolute requirements for health care in all countries, irrespective of their wealth.¹⁴ It is important that the WHO and the international surgical community work together to implement such programs. For both national and global reasons, it is appropriate for the CJS to have a section dedicated to international surgery.

Competing interests: None declared.

Accepted for publication Apr. 21, 2008

Correspondence to: Dr. R. Lett, Canadian Network for International Surgery, Wawanesa Bldg., #105, 1985 W Broadway, Vancouver BC V6J 4Y3; fax 604 739-4788; lett@cnis.ca