Surgery as a Global health issue.

Over the past decade, the concept of surgical care as a population-based, affordable, and globally relevant issue has gradually begun to emerge.[24,28,34,37] The facts are startling: more people die each year due to the inability to access surgical care than from human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), tuberculosis, and malaria combined.[6] The highest incidence results from (in descending order) accidental trauma (bone and soft-tissue injuries), tumors, obstetrical complications (including obstetrical fistula), cataracts and glaucoma, perinatal conditions and congenital anomalies, male circumcision (prevention of HIV transmission) and a large group (19%) under the heading of “Other,” which include a variety of diagnoses such as hernia, gall bladder disease, infections requiring surgical care, etc.[4,6] However, the global burden of disease (GBD) associated with surgical and obstetrical care has yet to be adequately defined; current numbers are likely to be artificially low.[27,36] While the total volume of actual surgical cases can be tallied, the unmet surgical need is only beginning to be measured.[29] It is not without reason that surgery has been termed the “neglected stepchild” of global public health and the “neglected specialty in the current global health arena.”[7,8] Historically, the primary barrier to developing surgical services has been the (mis)perception that surgery is overly expensive for the majority of lower and middle income countries (LMICs).[3] However, the World Bank published the 2nd edition of Disease Control Priorities in Developing Countries (DCP, 2006), which provided the first clear economic evidence that surgical care could be a cost-effective strategy under certain circumstances when compared with other types of care, such as antiretroviral medications, vaccinations, and other primary treatments. This economic impact was calculated on the basis of Disability Adjusted Life Years (DALYs), which is the sum of Years of Life Lost (YLL) plus the Years Lost due to Disability (YLDs) or simply: DALY = YLL + YLD. The purpose of surgery, however, is to alleviate or mitigate against certain physical conditions and the resultant “DALYs averted” reflects the reduction in calculated DALY as a consequence of the timely institution of appropriate surgical care. Surgical conditions account for 11% of global DALYs lost each year, with LMICs carrying the greatest burden; Southeast Asia plus Africa alone, accounted for 54% of DALYs in 2004.[6,9] Emergency and essential surgical care is increasingly recognized as a critical element to improving primary health care delivery. In the World Health Report 2008—Primary Health Care (Now more than Ever), the World Health Organization (WHO) included Surgery for the first time within the Primary Healthcare Sphere of Care.[22,35] This report emphasized the creation of primary care teams responsible for defined populations with access to all aspects of care, which was not splintered by economic concerns or differences. While inserting one word on an organizational chart appears to be a small step, it was a huge leap forward that required years of continual effort. Additionally, WHO has made surgical care a priority.[1,20] The Emergency and Essential Surgical care (EESC) of the WHO, has been active in the Global Initiative for Emergency and Essential Surgical Care (GIEESC), a forum of surgical experts. EESC has published the volume Surgical Care at the District Hospital (SCDH) in seven languages and produced the Integrated Management of Emergency and Essential Surgical Care (IMEESC) toolkit, a Compact Disc that contains the SCDH, a long list of best-practice protocols (including disaster management), multiple point-of-contact posters, and a number of instructional videos. Ongoing research within EESC includes a large database of surgical hospital capacity throughout the developing world (>700), capacity building through educational programs, and periodic follow-up of existing programs. Within the WHO, other areas of relating to surgery include Violence and Injury Prevention, Maternal and Child Health, HIV/AIDS (male circumcision), and transplantation. Surgery is credited with providing a critical role in achieving the United Nations Millennium Development Goals (MDGs) and is most closely involved with numbers 4, 5, and 6.[23] Although most directly linked to these MDGs, surgical care also indirectly, but significantly contributes to MDG 1: The eradication of poverty and hunger. This is due to the fact that restoring health to the man who is a primary provider (such as repairing an inguinal hernia so that he can return to work) and/or the woman who provides for the home and children (such as relieving obstructed labor or repairing a vesico-vaginal fistula), greatly reduces economic loss and/or emotional hardship.