Global Burden of Surgical Disease and the Role of Academic Surgery
Approximately 11% of the global burden of disease can be treated by surgery, a figure that is currently being challenged as a gross underestimation [1, 2]. Despite the improvement in worldwide morbidity and mortality that could be potentially gained by strengthening surgical systems in low- and middle- income countries, access to surgery has not been traditionally seen as a public health problem [3, 4]. Although surgery has been subsequently labeled as the “neglected stepchild of global health”, surgical diseases themselves have not neglected the world’s poor . Maternal mortality is orders of magnitudes higher in the developing world when compared to high-income countries, while over 90% of mortality due to unintentional injuries occurs in low- or middle-income countries (LMICs) [5 ,6]. Claiming more than 5 million lives annually, trauma alone kills more people than HIV, tuberculosis, and malaria, combined .
This disparity only threatens to become worse, as a global epidemiologic transition is currently underway. As progress is made in the treatment and prevention of infectious and childhood diseases in low-income countries, these regions are facing an increasing burden of non-communicable diseases. Many of these conditions also require surgical care, either for cure or palliation: Surgery is often a core component of cancer treatment, while people with diseases such as diabetes require more surgical care over their lifetime than those without. Despite this growing surgical burden of disease, most LMICs lack adequate human resources and/or infrastructure to provide timely surgical care to people with these conditions.
A small, but quickly growing, body of literature has emerged over the past 10 years shedding some light on the stark disparity between the burden of surgical disease in LMICs and the financial and human resources spent addressing it . Previously dismissed as too expensive, recent cost-effectiveness studies have estimated improvement in surgical services as much more cost effective than well-established and heavily supported antiretroviral therapy for HIV; as it turns out, surgery ranks among the spectrum of more cost-effective public health interventions, such as vaccines [2, 8, 9]. As the global burden of unmet surgical need is steadily revealed, and the previous myths preventing the acceptance of surgery as a public health issue are dispelled, a core of academicians dedicated to the study of this new field is emerging.
Good work in academic global surgery relies on solid, consistent, long-term relationships with LMIC partners; however this need is often in conflict with the traditional demands of academic clinicians. More than any other field, quality research in global surgery cannot be fit around the edges of an already packed clinical load and research agenda. Meaningful advances cannot be made in global surgery if it remains the second or third research priority of the academic surgeon.
To be done well, global surgery needs to be the primary research focus of select dedicated individuals who have the skillset and protected time to do the real work: cultivate and maintain real, long-standing relationships with LMIC partners; understand the complex contextual challenges; rigorously study the problem; provide evidence-based intervention and policy proposals; and challenge these hypotheses to study their effectiveness.
1. Debas H, Gosselin G, McCord C, et al. Surgery. In: Jamison D, Breman J, Measham A, et al, eds. Disease control priorities in developing countries, 2nd edn. New York: Oxford University Press; 2006:1245-1260.
2. Laxminarayan R, Mills AJ, Breman JG, et al. Advancement of global health: key messages from the Disease Control Priorities Project. Lancet. Apr 8 2006;367(9517):1193-1208.
3. Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg. Apr 2008;32(4):533-536.
4. Ozgediz D, Riviello R. The "other" neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med. Jun 3 2008;5(6):e121.
5. World Health Organization. Injury and Violence: The Facts. Geneva: World Health Organization Press;2010.
6. Hofman K, Primack A, Keusch G, Hrynkow S. Addressing the growing burden of trauma and injury in low- and middle-income countries. Am J Public Health. Jan 2005;95(1):13-17.
7. Hedges, J. P., Mock, C. N., & Cherian, M. N. (2010). The political economy of emergency and essential surgery in global health. World Journal of Surgery, 34(9), 2003–2006. doi:10.1007/s00268-010-0610-5.
8. Gosselin RA, Thind A, Bellardinelli A. Cost/DALY averted in a small hospital in Sierra Leone: what is the relative contribution of different services? World J Surg. Apr 2006;30(4):505-511.
9. McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: what it can mean for emergency obstetric care. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics. Apr 2003;81(1):83-92.