Improving surgical services in developing nations: getting to go.

In 2001, members of the United Nations and many important international health organizations established millennium development goals based on the United Nation’s Millennium Declaration, which was signed in 2000. These were goals that were to be achieved by 2015 if the social and economic well-being of the world’s poorest countries would be improved (http://www.un.org/millenniumgoals). Eight broad and expansive overarching goals were enumerated and these were to: (1) eradicate extreme poverty and hunger; (2) achieve universal primary education; (3) promote gender equality and empower women; (4) reduce child mortality; (5) improve maternal health; (6) combat HIV/ AIDS, malaria, and other infectious diseases; (7) ensure environmental sustainability; and (8) develop a global partnership for development. Although the most recent report indicates that some good outcomes have been realized, the overall progress to date has been slow and much work remains to be done. Furthermore, it appears that the gap between desired and accomplished outcomes may be greatest in sub-Saharan Africa where stronger ties and better coordination needs to occur among the various humanitarian, developmental, and economic missions (ref: Overseas Development Institute). Some key requirements for successful outreach programs were outlined in a consultation that was prepared to help guide President Barack Obama’s Global Health Initiative. This document articulated a belief that patient care in developing countries could only be optimally addressed by the effective and efficient development and use of countryled platforms. These were the best methods of improving health care delivery, and these were the platforms that would appropriately emphasize the delivery of essential health care and public health programs in a sustainable manner. Four components that were believed to be critical for success were identified: (1) do more of what works; (2) build on and expand programs that foster stronger systems and, thereby, yield more sustainable results; (3) innovate; and (4) collaborate for impactful results (http://www.usaid. goc/our_work/global_health/home_publications/docs/ghi_ consultation_document.pdf). A global health committee convened by the U.S. Institute of Medicine in 2008 to investigate the country’s commitment to global health problems and to define how the United States might best help address the world’s health care problems highlighted similar principles. Five key needs were identified: (1) a scaling up of existing interventions that have already been found to be effective; (2) to generate and share knowledge generated by studying the best health care delivery systems and rigorously evaluated their efficacy; (3) an investment in capacity building; (4) an increase in financial commitments for global health because such is an absolute requirement if poor countries are to meet the health related millennium development goals; and, perhaps most importantly, (5) how to engage in respectful partnerships to ensure that the developing countries retain ownership and accountability for their issues. It is increasingly apparent that there is a great need for surgical care in many, if not all, developing countries. For example, traumatic injury that might be amenable to surgical intervention accounts for a significant percentage of the loss of useful work capacity as defined by disability adjusted life years (DALY). Here, one ‘‘DALY’’ represents the loss of 1 year of equivalent work that an individual could accomplish at full health. Indeed, it is striking that the United Nation’s developmental goals do not more D. O. Jacobs (&) Department of Surgery, Duke University Medical Center, Durham, NC, USA e-mail: danny.jacobs@duke.edu