For years, the surgical practice has been an essential medicine to treat many diseases, such as benign lesions or neoplasms, deliveries, cesarean sections, infections, obstructions, bleeds, and cardiovascular diseases. In many cases, the standard of care is surgical intervention as the first-line treatment and often curative. Without surgical care, a health care system is inept at running properly.

The dilemma with surgical practice and its globalization is that it requires the coordination of skilled human resources, specialized supplies, and infrastructure, which is lacking in many developing countries.

Today, international organizations such as the World Health Organization and the World Bank base their support strategies on improving those countries’ health care system components for implementation in surgical practice. To date, this goal has not been achieved, and many communities still lack access to safe, affordable, and timely surgical and anesthesia care. The Lancet Commission on Global Surgery placed this estimate at nearly 5 billion people globally.

Epidemiology of surgery: a point of concern

In 2010, 32.9 percent of all deaths worldwide were attributed to conditions requiring surgical care which were unmet. This number greatly exceeded the number of deaths from HIV/AIDS, tuberculosis, and malaria combined.

Many countries with developing economies have not considered surgical care a public health priority. However, surgically treatable conditions—such as cataracts, osteomyelitis, hernias, obstructed labor, otitis media, and a wide variety of inflammatory diseases add a chronic burden of ill health to populations. These acute and chronic conditions take a severe human and economic toll and often lead to acute, life-threatening complications.

It is estimated, approximately 77.2 million disability-adjusted life-years could be averted by primary, life-saving surgical care, annually. Furthermore, as with so many global health challenges, the burden of untreated surgical conditions falls heaviest on individuals living in low-  and middle-income countries.

On the African continent, for example, there are fewer physicians per population than on any other continent. Furthermore, surgeons are even more scarce: predominantly practicing in urban enclaves leaving rural regions the most underserved. Additionally, according to a 2009 report, only 46 percent of births in sub-Saharan Africa are attended by skilled personnel, compared with 96 percent in Europe. They also found, on average, two physicians and 11 allied health staff to serve 10,000 people. This is in dramatic contrast with the continent’s European counterparts’ 32 physicians and 79 allied health staff to serve a comparable population size. This information can even be extended to regions in Asia and Latin America.

Health disparities

In low-income countries, death and disability from diseases that are surgical have received little attention and are not fully understood; failure to recognize and address the substantial human and economic cost of untreated surgical conditions in low- and middle-income countries slow progress toward a wide range of global health and development goals.

Also, securing and maintenance of surgical facilities within the current global health framework is costly, complex, and challenging, even more so when cooperation from government and financial institutions is required.

International proposed strategies to speed up surgical globalization

The concept of globalization. First, the concept of globalization must be taken into account. Per the Cambridge Dictionary, the term globalization means “A situation in which available goods and services, or social and cultural influences, gradually become similar in all parts of the world”. If applied to medical practice, globalization implies the accessibility of proper medical services in all parts of the world, mainly in low- and middle-income countries.

Health care management. The surgical system goes beyond an operating room, surgeon, and sterile environment. It also needs a functional blood bank, qualified staff, and an interpersonal network that starts from the community. An operating room does not stand for anything if it is not involved in a functional first-level health system with its community’s and surgical equipment suppliers’ cooperation.

Expanding accessibility. Regarding accessibility and delays in surgical care, the Three Delays framework, first described by Thaddeus and Maine in 1994, is often employed to elucidate this particular deficiency. The delays include: 1) Delays in seeking care, 2) reaching care, and 3) receiving care once the patient arrives at the facility.

Governments, for-profit and not-for-profit institutions, and global organizations should strive to address these three backlogs by ensuring adequate community health education and transportation infrastructure and providing health care facilities with the necessary personnel, technology, and supplies.

Increase the workforce: education, training, incentives. Human capital is the single most important asset of any health system. According to the Lancet Commission for Global Surgery, a significant global surgical workforce shortage is furthermore exacerbated by an unequal distribution of said workforce, both within and between countries. This creates a substantial inequity in health care.

Bearing the aforementioned in mind, it should come as no surprise that low-income countries are disproportionately affected by low surgical workforce densities. It is therefore of paramount importance these deficiencies be remedied alongside medical infrastructure development.

While acknowledging the importance of a diverse, multidisciplinary health system, the primary focus should be placed on developing and retaining the three most critical elements of the surgical workforce: surgical, anesthetic, and OB/GYN providers.

Increasing the availability of these providers in low- and middle-income countries centers around education and financing. We must first start with student preparedness. Increasing access to primary and secondary education for all children is of paramount importance. Additionally, an intensive undergraduate-graduate-professional education, training, and retention framework needs to be established and nurtured. Recruitment, matriculation, and minimization of attrition throughout the education process, followed by retention of graduated surgical workforce professionals once their education is completed, will ensure a steady-state supply of human resources. This is the bedrock of how to meet the surgical needs of citizens of the countries.  Only then may facilities, ancillary services, standards, and quality assurance needs be competently addressed.

Jeremy Goodwin is a medical student.

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