Non-Communicable Disease – the 21st Century challenge? A closer look at the role of surgery in global health

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Current Context

In recent decades, the world has witnessed a shift in the epidemiological trend. The burden of disease has progressed from acute illnesses of infection to those of degeneration and man-made origins 1. Specifically in low and middle-income countries (LMICs), where there are growing influences of industrialisation and modern technological advancement, it is predicted that over the next 20 years cancer, heart disease and road traffic accidents will surpass prior communicable disease challenges2. We see this in high-income nations as well, where the leading cause of death today remains ischaemic heart disease 3.

Recently, one field has emerged as an indispensible tool for treating non-communicable diseases – global surgery. There has been a newfound appreciation that surgical treatment serves as a cost-effective measure for dealing with such problems. Unfortunately, prior efforts to incorporate surgical initiatives have been largely unsuccessful and as such there has been a global deficit of essential surgical interventions. Especially in light of the 2010 estimates that 321.5 million inpatient surgical procedures are needed to address the present-day global burden of disease, experts can now agree that current health care models need to adapt 4,5.

It has been predicted that, as of 2007, approximately one-third of the world’s population still lacks access to basic surgical care6. While some studies argue that this figure has improved in recent years, there is no question that global surgery has, until recently, been labelled as the ‘neglected stepchild of global health7. As a result, public-health initiatives have had to adjust their focus to prioritise surgery as an integral component of preventative and curative medicine.

The annual World Health Assembly in 2015 marked a milestone in the amelioration of global surgery with the passage of Resolution 68.1.5. This motion called to incorporate surgical care and anaesthesia as a key element in universal health coverage 8. Since then there has been a growth in efforts to extend the scope of such services – from the WHO’s Emergency and Essential Surgical Care programme to the World Bank’s Disease Control Priorities project 9. The overall goal of these initiatives is to identify feasible methods of promoting medical services and integrating surgical care at the primary referral level.

The role and importance of global surgery

To understand how surgical services should be prioritised, it is important to first answer the question of when surgical intervention is necessary. One author defines it as “any condition for which the most potentially effective treatment is an intervention that requires sutures, incisions, excisions, manipulations, or other invasive procedures that usually, but not always, require anesthesia”10.

We already see the importance of surgery on non-communicable diseases in modern day medicine; cataract surgeries, tumour resections, and total hip replacements are among the few types of procedures performed regularly in LMICs. Likewise, when impractical measures such as visiting dialysis centres regularly for chronic kidney disease fail, surgical treatment is often the only clear solution.

To the dismay of global surgical advocates, public health ideas often relegate the importance of surgery when they regard it as a form of treatment once disease has occurred, rather than a means of prevention. Today, preventative surgery has been validated several novel procedures observed in high-income communities – such as the bilateral mastectomy performed on positive BRCA gene patients or the precise laser peripheral iridotomy as prophylaxis against acute angle closure glaucoma.

One study argues that surgery should be regarded only as an essential solution to the prevention of death and disability; however it also goes on to emphasise another overlooked asset of surgical treatment – preservation of economic productivity 11. Basic surgical care today is not of great precedence in many national policies 7. This is largely due to a longstanding misconception that providing surgical care in a rural setting is expensive, is labour intensive and provides little tangible return. However, thanks to increased interests in the economics of providing surgical care in LMICs, research has come to the conclusion that across multiple sub-specialties, surgery is extremely financially worthwhile 11. Above all, ignoring this need could result in a loss of US $12.3 trillion over the next 15 years 2. A good way of conceptualising this is to look at deaths from traumatic injuries, for example. These account for 1 in 10 deaths worldwide and most individuals involved in these accidents fall between the ages of 15-44 years 12,13. Of note, these years make up the most economically prolific division of the population and often times these individuals are the breadwinners in the family 13.

Existing literature on challenges

In order to address the challenges faced with tackling non-communicable diseases, it’s imperative to specify the obstacles to effective solutions.

Disparities in global surgery exist today and will continue to exist. While providing care in any health care specialty in LMICs or rural settings comes with difficulties, an initial consensus is that some barriers are more pertinent to surgical disciplines. 14. The Lancet Commission on Global Surgery, published in 2015, largely addressed these issues and elucidated the current state of surgical care. In collaboration with 25 commissioners and advisors from over 110 countries, the report has laid out concrete ground work for tackling today’s on-going issues 2.

The paper focused on three main topics: accessibility, affordability and availability. Each category is equally as important when understanding the current situation in many LMICs. The report outlines that beyond the team of surgeons and anesthetists delivering the care, there is an incredible responsibility in the pre-hospital network. This includes community health care workers who connect patients in remote areas to primary care centers; non-governmental organizations (NGOs) that refer patients to appropriate administration teams; and public and private sectors that are all involved in getting the patient to the right place 2.

Current literature further categorizes these barriers into three areas of focus: structural aspects of health care, cultural beliefs and attitudes, and financial barriers 15. A recent systematic review explored 52 published studies that addressed barriers to surgical care access in various LMICs. Among the cohort of papers, there were various surgical specialties explored and several countries that had been included. Interestingly the vast majority of the papers concluded that financial barriers are still the root and the greatest contributing factor to inaccessibility of medical and surgical care 15.

Leaders in finding solutions

Present day research continues to strive for solutions to the issues addressed above. The Lancet Commission remains a strong leader in the field. The authors agree that in order to rally further action, there needs to be a global collaboration. Of their proposed future projects, one involves a national surgical plan that focuses on the deliverance of surgical care. Their plan details several recommendations for improvements in infrastructure, workforce, service delivery, financing, and information management. The hope is their work and research will help others recognise the impact of globalising surgery on the challenges we have yet to face in the future of global health care 2.

For other research groups, the idea of global surgery is still a very new concept that has only recently taken off amongst the global health community as a robust answer to ongoing problems. To gain comprehensive insight on the issues in more remote communities there is urge for more data collection and research. A crucial aspect in this conversation, research has the capacity to identify specific areas that need further developing and to monitor the effect of proposed changes. Recommendations from global health communities include the increase in funding for international partnerships and research facilities 2,4.

Conclusion

Non-communicable diseases are inevitably going to be one of the greatest challenges on the platform of tackling the futures global health concerns. This is not just the case for LMICs, but a concern that is growing among high-income nations as well. Fortunately there are novel solutions to tackling this challenge and one of the front-runners in this discussion is global surgery.

Despite its challenges, global surgery is a fresh approach to an unfaltering issue. Where there are gaps in our understanding of its impact and setbacks, there is extensive research that continues to shed light on what global communities are faced with when seeking medical treatment.

Coupled with the ongoing efforts to reform current global health guidelines, there is a call for new and updated research in LMICs and other communities that are difficult to access. With combined efforts from various platforms and specialties, great promise lies ahead for this upcoming field and hope for an answer to some troubling problems.


During Kathryn Yang’s first week in a Cambodian surgical clinic last summer, she witnessed a 5-hour long Krukenberg procedure, transforming a forearm amputation into a makeshift pincer using the patient’s ulnar and radial bone. Currently a final-year medical student at the University of Manchester, Kathryn’s research in Phnom Penh has inspired her to spur conversation around the growing field of global surgery.

Interested in Global Surgery?

The Incision Network is the International Student Surgical Network, a collaboration of medical students globally who have come together to discuss, educate, advocate for, and perform research within the realms of Global Surgery.


REFERENCES

1. Omran, A. The epidemiologic transition: a theory of the epidemiology of populatuon change. Milbank Mem. Fund Q. 49, 509–538 (1971).

2. Meara, J. G. et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. The Lancet 386, 569–624 (2015).

3. WHO. WHO _ Cardiovascular diseases (CVDs). Cardiovascular diseases (CVDs) (2015). doi:Fact sheet N°317

4. Rose, J. et al. Estimated need for surgery worldwide based on prevalence of diseases: A modelling strategy for the WHO Global Health Estimate. Lancet Glob. Heal. 3, S13–S20 (2015).

5. Taira, B. R., Kelly McQueen, K. A. & Burkle, F. M. J. Burden of surgical disease: does the literature reflect the scope of the international crisis? World J. Surg. 33, 893–898 (2009).

6. Contini, S. Surgery in developing countries: why and how to meet surgical needs worldwide. Acta bio-medica : Atenei Parmensis 78, 4–5 (2007).

7. Farmer, P. E. & Kim, J. Y. Surgery and global health: a view from beyond the OR. World J. Surg. 32, 533–536 (2008).

8. Price, R., Makasa, E. & Hollands, M. Health Assembly Resolution WHA68. 15:‘Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage’—. World J. Surg. 39, 2115–25 (2015).

9. Spiegel, D. A., Abdullah, F., Price, R. R., Gosselin, R. A. & Bickler, S. W. World health organization global initiative for emergency and essential surgical care: 2011 and beyond. World J. Surg. 37, 1462–1469 (2013).

10. Ozgediz, D. et al. Population health metrics for surgery: Effective coverage of surgical services in low-income and middle-income countries. World J. Surg. 33, 1–5 (2009).

11. Grimes, C. E., Henry, J. A., Maraka, J., Mkandawire, N. C. & Cotton, M. Cost-effectiveness of Surgery in Low- and Middle-income Countries: A Systematic Review. World J. Surg. (2013). doi:10.1007/s00268-013-2243-y

12. WHO. the Injury Chart Book. Int. Classif. 81 (2002).

13. McQueen, K. A. K. et al. Burden of surgical disease: strategies to manage an existing public health emergency. Prehosp Disaster Med 24, s228–s231\rM3–10.1017/S1049023X00021634 (2009).

14. Donnell, O. O. Access to health care in developing countries : breaking down demand side barriers. Cad Saude Publica. 23, 2820–2834 (2007).

15. Grimes, C. E., Bowman, K. G., Dodgion, C. M. & Lavy, C. B. D. Systematic review of barriers to surgical care in low-income and middle-income countries. World J. Surg. 35, 941–950 (2011).

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