Global Surgical Burden

by Joe Incorvia and Ben Kuo

Today, we’d like to tell you the story of two mothers, Mary and Awusi, who are both incredibly driven to give the best lives to their families. Hailing from Cary, NC and Anomabo, Ghana, respectively, their access to medical care differ greatly, therefore impacting their decisions.

Let’s see what’s going on with Mary first. It is a brisk Sunday morning around 10 am and Carter, Mary’s 17 year-old son has been complaining about his stomach all morning. He describes a strong pain in his abdomen, to which his mother gives him some Tums and tells him to lay down and rest... Just over 5300 miles away, Awusi notices that Coffie, her eldest son (19 years-old) is unusually tired from his day. He’s sitting outside and clutching his side, telling her he has been in serious pain all day. She tells him to go find Appiah, who takes the role as the community’s healer when the medical brigades aren’t near...

Back stateside, it’s now 1pm and Carter’s pain has gotten to the point of unbearable, he’s vomited multiple times and has a low grade fever. Worried, Mary decides to take him to the hospital. She helps Carter uncomfortably walk to the car and takes off for Duke Medical Center... Appiah has been with Coffie for about a few hours now, Awusi arrives as well to see that her son is writhing in pain. She is told that he needs more help and should head to Finney Hospital in Accra, nearly 100 kilometers away. She hopes she can find Owusu who has a car and can drive her there…

Arriving at Duke Medical Center, Mary and Carter sign in and wait. After about 40 minutes, Carter is taken back for a CT scan diagnosing his ailment as appendicitis. He is scheduled for surgery for the next open slot and will receive it in about 4 hours, he is put on medication to help his pain while he waits… Every bump in the road aggravates Coffie as the pain continues to get worse, he’s nauseous and clutching his side in the back seat of the truck. It’s been 7 hours since he went to see Appiah and the remedy he was given has not helped since leaving. Upon arriving at Finney, they see many people lined up inside the hospital. They go inside explaining their problem and are told that hospital staff will keep checking in, but they most likely won’t have any beds available until morning…

How well do you think the prognosis will be for our two suspected appendicitis patients? Well, based on our talk from Dr. Rice and the theme of this section, there are some important points to consider. Before even talking about possible appendectomies, we need to consider the events leading up to diagnosis (or in Coffie’s case, getting to the hospital). Much of the global surgery burden comes from a disparity in access in many Low-Middle Income Countries (LMICs). Road infrastructure, cultural attitudes toward surgical intervention, and financial constraints all play a role in making medical decisions. In the United States, we may be fortunate enough to be able to hop in a car and head quickly to the nearest major medical center for emergency care, knowing that we may be able to have the fund to cover care as well as faith in the medical system to help out ourselves or our loved ones. However, 5 billion people do not have access to safe, affordable surgical and anaesthesia care when needed. Access is worst in low-income and lower-middle-income countries, like Coffie’s home nation of Ghana, where nine of ten people cannot access basic surgical care (Meera et al, 2015).

It’s simply not just a point of disparity of access, but also disparity of capacity of surgical care. In fact, 143 million additional surgical procedures are needed in LMICs each year to save lives and prevent disability. Of the 313 million procedures undertaken worldwide each year, only 6% occur in the poorest countries, where over a third of the world’s population lives. Low operative volumes are associated with high case-fatality rates from common, treatable surgical conditions (Meera et al, 2015). That could mean that a procedure we take for granted as being simple and commonly nonfatal, such as an appendectomy, could prove to be an issue for LMICs to diagnose or treat well. And even if the diagnosis is correct, there may not be the ability for a health center to be able to provide the proper surgical care needed, increasing mortality and disability rates.

So let’s venture back to our story one more time. Hypothetical, yes, but it still brings up a point about access to basic surgical care. It appears to be much easier for Carter to get access to proper surgical care at a health center able to provide it than Coffie can. That is unfortunately the case in many LMICs when compared to HICs like the United States. Now, while Carter could have complications and end up having a negative outcome and Coffie could end up getting a bed and being treated without issues, the chance of those alternative scenarios happening are directly correlated to the access and capacity disparities talked about in the literature, and the disparities increase when talking about more complicated procedures like cesarean section and neurosurgical care. 

Disparity in Surgical Need across different regions

United States
Surgical Unmet Need per 100,000	0
Surgical Rates per 100,000	>20,000
Ratio of Met to Total Need	4.01
Global Target	5,000

Sub-Saharan Africa (western)
Surgical Unmet Need per 100,000	5,625
Surgical Rates per 100,000	<100
Ratio of Met to Total Need	0.11 (1/9)
Global Target	5,000

Rose et al., 2015, Estimated need for surgery worldwide based on prevalence of

diseases: a modelling strategy for the WHO Global Health Estimate.

The Lancet Global Health

Global surgery burden is exactly what it sounds like: a global issue. Today’s surgical workforce would need to increase by 2.2 million to be able to reach the target of 80% coverage for timely access of primary surgical care for 2030. The cost of surgical expansion would be around $350 billion and the lost output will cost LMICs $12.3 trillion (Meera et al, 2015). The conversation around increasing care can be done in an affordable way that can help not only save money, but save lives. A solution to this problem could help create positive outcomes for individuals like Carter and Coffie across the entire Earth.

High Priority Intervention Areas

Area in Need	2030 Global Lancet Commission Targets
Access to timely essential surgery	80% coverage of essential surgical and anesthesia services per country
Surgical workforce density	100% of countries with at least 20 surgical, anesthetic, and obstetric physician per 100,000 population
Surgical Volume	A minimum of 5,000 procedures per 100,000 population
Perioperative Mortality	100% of countries tracking perioperative mortality
Protection against catastrophic expenditure	Systems to protect out-of-pocket payments for surgical and anesthesia care

Meara, J. G., Leather, A. J. M., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. a., … Yip, W. (2015). Global Surgery 2030: 

Evidence and solutions for achieving health, welfare, and economic development. Surgery, 3–6. 

Things to Ponder:

With these proposed targets that are collaborative in nature, how do we ensure accountability between healthcare professionals, governments, global organizations (WHO, World Bank), and other stakeholders? Do you all think that these goals are feasible? Let us know in the comments below.

-       Ben and Joe

All figures from: Meara, J. G., Leather, A. J. M., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. a., … Yip, W. (2015). Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Surgery, 3–6