Global surgery: fatally neglected?
This year, Polygeia has assigned a group to look into the field of Global Surgery. This area has been recognised by the World Health Organisation and many others as an increasingly important area within Global health, yet it has been largely neglected in terms of previous studies and analysis. In 2010, HIV killed 1.46 million people, Tuberculosis killed 1.2 million, and Malaria 1.17 million. The Lancet estimates that a lack of surgical care led to 18.6 million fatalities in that year alone. 
The goal of the Lancet Commission in Global Surgery is “access to safe emergency surgical care and anaesthesia when needed, with financial protection”.  This may sound simple, yet it is anything but; to understand the complexities involved in achieving it, we must consider the journey of the surgical patient.
Before a surgeon of any description can begin to treat a patient, patients must get themselves to medical care. Part of this comes down to patients recognising that they are sick and need medical attention. Even once a patient is aware they need healthcare, they may well delay being seen by a doctor for a multitude of reasons: they cannot afford to be off work because they are the sole breadwinner, they simply cannot get to the facility, or they might not be able to afford the hospital bills. One in four patients who undergo emergency surgical care in low- and middle-income countries (LMICs) suffer financial catastrophe after the procedure.  This means that when patients do finally present to healthcare professionals, they are often more acutely unwell and in greater need of expedited care.
One of the proposed Lancet metrics for measuring how well a country provides surgery is “percentage of population with access within 2 hours to a facility capable of safe emergency surgery”.  In the heart of London, major trauma centres are minutes away, via well-suspensioned, clean, staffed ambulances. In some LMICs, the nearest surgical facility is days away with the only transport being a cart driven by the local farmer. Improving rapid access to healthcare is a vital component of Global surgery.
In nearly every healthcare setting in the world, when a patient arrives they undergo some form of triage in order to assess the urgency of their needs. They will need to be managed appropriately and have a surgical and anaesthetic consultation before undergoing definitive treatment. The UK target of a maximum of four hours in A&E is an unachievable, unreasonable dream in a Ugandan rural hospital. Within that time, conditions may easily deteriorate from easily manageable to life-threatening. It is estimated that with timely surgery, 90% of maternal mortality could be avoided.  According to the World Bank, in 2015 in the Central African Republic, the mortality rate for mothers was 882/100,000. With appropriate surgical resources, that could be reduced to below 90/100,000.
The provision of definitive treatment is by no means guaranteed. The “Bellwether procedures”, as defined by the Lancet, are three basic operations that give a good indication of surgical provision. They are Caesarean-section operations, laparotomies, and the repair of open fractures. 64% of surgical centres provide Caesarean procedures, but only 40% can fix an open fracture and less than 60% are able to perform a safe laparotomy. 
The cost of improving global surgical provision over the next 15 years is estimated at 350 billion US dollars (USD) – a sizeable sum. However, it is orders of magnitude smaller in comparison to the estimated GDP loss over that time; predicted by the Lancet commission to be at 12.3 quadrillion USD.  Expanding surgery is an investment opportunity that gives returns that Wall Street bankers could only dream of.
Overall, it is clear that surgery, while clearly such an integral part of a healthcare system, has been neglected worldwide at vast human and economic cost. It is our team’s aim to identify the improvements than can be made and address how they may be achieved.
Frederick Stourton is a third year medical student at Imperial College London. He has previously worked for the Cruz Verde in Guadalajara, Mexico, providing Surgical and Pre-Hospital Emergency care.
1) The Lancet TV. The Lancet: Global Surgery. [Video]. Available from http://www.lancetglobalsurgery.org/ [Accessed 19thMarch, 2016]
2) Lancet Commission in Global Surgery Information Management Working Group. Progress Report, June 2014. [Presentation]. Available from http://www.globalsurgery.info/wp-content/uploads/2013/11/Russel-Gruen.pdf [Accessed 19th March, 2016]
3) World Bank. Maternal Mortality Ratio (modeled estimate, per 100,00 live births) [sic]. Available from http://data.worldbank.org/indicator/SH.STA.MMRT [Accessed 19th March, 2016]
4) Lancet Commission in Global Surgery. Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare, and Economic Development Policy Brief. Available from http://media.wix.com/ugd/346076_23b4c3a24c594888a8f0e077195dc5d8.pdf [Accessed 20th of March, 2016].