The Cutting Edge of a Global Public Health Family
Bringing Surgery into the Fray
By Ambereen Sleemi
Published May 22, 2014
In Mendefera, Eritrea, I am part of a small team of visiting surgeons who work with and train local surgeons to care for women with severe maternal birth trauma. This trauma is almost always the result of lack of access to emergency obstetric care, primarily a cesarean delivery. The women we care for, like Elsa, who labored at home for two to three days before her family could bring her to the hospital, are mostly poor.
In most cases, the baby dies, but the agonies of childbirth in a resource-deprived setting do not end there.
Prolonged labor, usually treated by a cesarean delivery, causes severe damage to the vaginal birth canal, resulting in damaged tissue that sloughs off, leaving holes between the bladder and vagina, and sometimes, between the rectum and vagina.
After her ordeal, Elsa sustained nerve damage. She constantly leaked urine, and was plagued by and a sense of shame and embarrassment. Our team operated successfully, and Elsa recovered fully, returning home to her family with a restored sense of confidence.
Surgical procedures that we often take for granted are able to prevent or repair damages that otherwise would be both devastating and permanently life altering. Despite their profound implications, access to surgeries like the one our team performed on Elsa remains effectively absent from the global public health agenda.
The Neglected Stepchild of Global Public Health
In 2008, Dr. Paul Farmer and Dr. Jim Kim wrote a definitive article on the role of surgery as the “neglected stepchild of global public health.” Drs. Farmer and Kim emphasize that an alarming lack of physicians in low-resource areas is eclipsed by the lack of surgeons, who remain concentrated in large urban centers, resulting in many days of travel for the rural poor.
On the international global health agenda sit many diseases that are treatable by surgical procedures, namely maternal hemorrhage, obstructed labor, motor-vehicle accidents, blindness, and traumatic farm accidents.
Over 250,000 women die annually in childbirth. Life-threatening maternal conditions relieved by surgery include cesarean delivery to treat labor that does not progress (i.e. obstructed labor), potentially saving the lives of both mother and child, and hysterectomy, or removal of the uterus, which can arrest severe maternal hemorrhage and prevent her death.
If a mother survives obstructed labor and/or hemorrhage, the lasting sequelae are vast—weakness, severe anemia, infertility, and neurologic trauma resulting in chronic pain or difficulty walking, resulting in a condition called “footdrop”. These conditions can hinder both a family’s nuclear and economic development. Other complications such as chronic urinary or fecal incontinence are conditions that potentially can be treated by surgical interventions, and can literally give a woman her life back.
Among the very poor in low-income countries, motor vehicle and farm accidents, blindness caused by cataracts or glaucoma, and peritonitis are conditions surgically treatable. Surgical conditions account for up to 15 percent of total disability adjusted life years (DALYs) lost globally. Pediatric conditions that can be treated with evidence-based procedures that are safe and effective, such as congenital cleft-lip and palate, cardiac disease due to infection or birth defects, and clubfoot, are left to develop into tremendous burdens on the individuals, the families and the communities that care for those affected. The loss of productivity of our world’s bottom billion is of paramount consideration.
The Great Divide
In addition to the dearth of surgical services available, another axis of inequality exists. Most surgical services are found in urban environments and reserved for those who can pay for them. In Haiti, for example, an early study showed that the rate of cesarean deliveries in rural areas was almost non-existent, but among the wealthy, the rates rivaled those of the U.S. At this time, the maternal mortality rate was 1,400 per 100,000 live births. It was not until 2007 that the Haitian central district health commissioner announced that all emergency obstetric services would be free of charge. There still remain staggering numbers of people without access to treatment for trauma services, emergency abdominal conditions such as ruptured appendices, intestinal obstruction and other potential fatal conditions.
There is no global funder or organization that focuses on the inequity of surgical care. No major donors have proclaimed a willingness to acknowledge surgery as global health crisis. Surgery is not included in the any of the U.N.’s 2015 Millennium Development Goals, but seems key to achieving 3, 4 and 5: promoting gender equality, reducing child mortality and improving maternal health, as noted previously.
Injuries and Insults
Some experts contend that much of this neglect is due to common misconceptions about surgical interventions. Many think surgical care can only address a small portion of the global disease burden. Still, surgery is often the only means to address injury, which according to the WHO’s 2002 Injury Chart Book, kills more than 5 million people worldwide annually. Many victims are the primary household earners and almost 50 percent of the injuries occur in 15-44 year olds, which is the most economically productive portion of the population. Similarly, a significant proportion of congenital anomalies and obstetric conditions, which together are responsible for over 600,000 deaths annually worldwide, can be treated surgically and avert many thousands of deaths from these conditions.
Another misconception is that surgical care is cost-prohibitive to implement widely. Surgery is seen as a highly technical discipline that requires an abundance of specialized equipment. While that may be true in some cases, surgery can also be cost-effective when compared to some common non-surgical public-health interventions. For example, the cost per DALY for emergency obstetric care in Bangladesh is approximately $11 (USD) per DALY averted and over $32 in Sierra Leone. These figures are comparable to common public heath interventions like vitamin A distribution ($9 per DALY averted) and measles immunization ($30 per DALY averted).
In a recent conversation with Dr. Adam Kushner, co-founder of Surgeons Overseas, he stressed that there needs to be a surgical component to the health system. “We’re not talking about going in and doing a single operation, but setting up surgical care for the entire population and that requires the appropriate personnel, infrastructure, equipment, supplies and training,” Dr. Kushner says.
Finally, in the context of low-resource settings, global surgery usually takes the form of short-term surgical mission trips, contributing to a kind of patchwork aid, which is the object of criticism. The role that these trips plays is one that may be beneficial, but cannot substitute for a nation’s ability to invest in the long-term development of a medical infrastructure that sustains surgical capacity. Such health infrastructure must not only provide care for the entire population, including the most marginalized and vulnerable, but also commit to staff development and training of its future healthcare workforce with medical and nursing schools and post-graduate training. Drs. Farmer and Kim encourage us to not abandon the short-term surgical trips, but to do them better, by integrating them into broader public health efforts.
Uniting and Paying It Forward
The role of surgery needs to be recognized as integral to the broader goal of global public health initiatives to build a sustainable health care delivery system that improves health and supports its ability to meet population demands. A recent survey evaluated the basic infrastructure of hospitals and health centers in five countries in sub-Saharan Africa and the ability to provide the most basic emergency and surgical care. None of the over 2,000 surveyed hospital or health facilities met the minimum requirements of infrastructure that the WHO has deemed essential for the provision for emergency and surgical care, from electricity and infection control to quality assurance and supervision of providers. The authors urge donors and organizations to recognize the need for investment in strengthening infrastructure, much like efforts to stem HIV. In this way, the global community pays it forward, and in the end, as with HIV, cost effectiveness will be achieved.
While surgery may be thought of as the ultimate individual intervention, it is indeed a public health issue. As Dr. Ray Price, of the University of Utah, a practicing surgeon in the U.S. and in low-middle income countries states, “We need to put the surgical language in an understandable language of our public health colleagues.” And as Drs. Farmer and Kim note, the global health need can be met with a collaborative approach to “build a coherent movement that comes to include surgery.”
Isn’t it time we all sat at the table together, even if it hurts just a bit? Lives like those of Elsa depend on it.
Edited by Dana March