More surgery and surgeons needed world-wide

"In the absence of surgical care, common, easily treatable illnesses become fatal," says Andy Leather, Director of the King's Centre for Global Health, King's College London, "The global community cannot continue to ignore this problem - millions of people are already dying unnecessarily, and the need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst affected countries face rising rates of cancer, cardiovascular disease, and road accidents."

The number of surgeries performed worldwide has grown steadily, particularly in the developing world, yet there remains an enormous gap in surgical care between rich and poor nations, according to a study led by a Stanford University School of Medicine researcher. 

Between 2004 and 2012, the estimated annual number of operations around the globe rose 38 percent, from about 224 million to nearly 313 million, the researchers found. The biggest increase, 114 percent, occurred in relatively poor countries. Yet these developing countries still account for a small percentage of operations overall. Only 6.3 percent of surgical procedures were done in the very poorest nations, which account for nearly 37 percent of the world's population, suggesting a vast unmet need for care, the researchers report. Moreover, the most frequently performed operation in poor countries was cesarean section, which accounted for 30 percent of the total, suggesting other significant surgical needs, such as traumatic injuries and cancer care, are being given low priority, Weiser said. In 2012, for instance, only 30 percent of surgical procedures were done in very-low- and low-expenditure countries, though these nations comprise 71 percent of the world's population. And the bulk of these procedures were C-sections.

"Surgery is being provided with increasing frequency in countries with very low expenditure on health care. Yet there is still a huge disparity between what is being offered in high health-expenditure countries versus the low-resourced countries," said Thomas Weiser, MD, an assistant professor of surgery at Stanford and lead author of the study. In addition to issues of access to surgery, Weiser said there is concern about the quality and safety of care provided in developing countries, where inadequate equipment and training, and a lack of sterile environments, can put patients at risk.

These concerns are the focus of a separate study in which he and his colleagues found high mortality rates and great variability in outcomes among patients undergoing three common procedures—C-section, appendectomy and hernia repair—in low- and middle-income countries.

"Surgery is a high-risk intervention," Weiser said. "We are talking about millions of operations a year, so a lot of patients are at risk. Safety is an important part of a care delivery strategy."

He went on to say, health systems in low- and middle-income countries have put a priority on managing infectious diseases and on maternal and child health. While these are still significant health issues, industrialization and aging populations have contributed to greater prevalence of other, noncommunicable conditions, such as heart disease and cancer, as well as traumatic injuries, Weiser said. These medical conditions often require surgical intervention, yet little is known about the availability of surgical care in many parts of the world, he said.

In the study, he and his colleagues at two Boston hospitals set out to obtain up-to-date and accurate figures on global trends in surgery, and country-by-country estimates of surgical volume for all 194 member nations of the World Health Organization. They scoured recently published literature, queried individual ministries of health and obtained data for some countries from the Organization for Economic Co-operation and Development. For many countries, however, there was no information available.

"In resource-poor settings, they don't have the capacity to provide the full repertoire of services," Weiser said. "So they focus on the high-impact services—the ones that are given priority, like maternal health."

The results are in keeping with the 2015 report from Lancet Commission on Global Surgery, which found that some 5 billion people lack access to safe, affordable surgical care and that an additional 143 million operations were needed to meet emergency and essential needs. A third of all deaths in 2010 (32·9%, 16·9 million deaths) were from conditions treatable with surgery - well surpassing the number of deaths from HIV / AIDS, TB, and malaria combined. Yet, despite this enormous burden of death and illness - which is largely borne by the world's poorest people - surgery has, until now, been overlooked as a critical need for the health of the world's population. The latest study reinforces the need to invest in both human and physical capital to help build effective surgical capacity in the developing world.

"One is a skills issue. There aren't enough providers, and there's obviously a brain-drain issue, as trained providers leave their home countries to practice elsewhere," he said. "Surgery is a very unsupported discipline in some parts of the world, in terms of infrastructure, and it's high-risk. ... A lot of those fundamental issues need to be addressed."

According to Lars Hagander, from Lund University, Sweden, "Too many people are dying from common, treatable surgical conditions, such as appendicitis, obstructed labour, and fractures. The problem is especially acute in the low- and middle-income countries of eastern, western and central sub-Saharan Africa, and South and Southeast Asia."