While access to surgical care and the burden of surgical disease have historically been neglected by the global health community, there is growing evidence that providing surgical services should be considered a global health priority. In 2006, surgical disease was estimated to contribute to at least 11% of the world’s disability-adjusted life years1, but experts believe this is a gross underestimation, with current estimates closer to 30%.2 One of the greatest barriers to care is a dearth of surgeons and surgical caregivers, revealing startling disparities in access to care and outcomes. Africa, for example, has only 1% as many surgeons as the United States.3 Over 90% of injury deaths occur in low and middle-income countries (LMIC), which account for more deaths than AIDS, TB, or malaria combined in children over the age of five.4,5 Yet, funding towards surgical development has historically accounted for less than 1% of the World Health Organization’s budget.6
The World Journal of Surgery published an article in 2008 by Dr. Paul Farmer and Dr. Jim Yong Kim, world experts on global medicine and global health development, calling surgery “the neglected stepchild of global health”.7 At that time, while global health involvement and volunteerism by surgeons was commended, it was hardly recognized as a viable integrated clinical or research pathway by academic departments or traditional funding agencies. That is, perhaps, no longer the case as increased advocacy and research in global surgery is creating a paradigm shift in global health. The results of the Lancet Commission on Global Surgery have been widely publicized, revealing estimates that five billion people worldwide lack access to affordable and safe surgical and anesthesia care.8 In May 2015, the World Health Assembly passed a resolution including Strengthening Emergency and Essential Surgical Care and Anesthesia as a Component of Universal Health Coverage9, an epic resolution for the global surgical community and an impetus for nations to develop national plans for surgical, obstetric, and anesthesia care as well as for multinational aid and funding organizations to include options for global surgical development.10 Cancer morbidity and mortality disproportionately affects LMIC; of 15 million new cancer diagnoses in 2015, over 80% will require surgery, and half of those will not have access to safe surgical care.11 Finally, the global burden of surgical disease is reaching the ears of surgical academia. Over the past five years, global surgery committees, speakers, and separate abstract tracks have been added to most major surgical conferences. The American College of Surgeons is starting collaborative training initiatives in sub-Saharan Africa, and global surgery centers are sprouting at major academic institutions.
Thus, “Global Surgery” has risen as an emerging field in both global health and academic surgery. Many people see global surgery as volunteer missions, and while these play an important role in providing services to needed populations, they often fail to address the underlying issues of sustainable healthcare delivery. The broader and more academic view of global surgery focuses on developing sustainable partnerships to understand the complex, transnational issues related to providing equitable surgical care in diverse populations. Global health programs not only provide transformative trainee experiences that foster improved cultural competence, systems-based practice and resource-utilization, but also increase the likelihood that a trainee will practice in or with an underserved patient population. At the University of Florida, this fits well with the broader vision of the UF Quality Enhancement Plan “Learning Without Borders”.
Background written by R. Petroze (October 2020)
- Debas HT, Gosselin R, McCord C, Thind A. Surgery. In: nd, Jamison DT, Breman JG, et al., eds. Disease Control Priorities in Developing Countries. Washington (DC)2006.
- Shrime MG, Bickler SW, Alkire BC, Mock C. Global burden of surgical disease: an estimation from the provider perspective. Lancet Glob Health 2015;3 Suppl 2:S8-9.
- Ozgediz D, Riviello R, Rogers SO. The surgical workforce crisis in Africa: a call to action. Bull Am Coll Surg 2008;93:10-6.
- Reynolds TA, Stewart B, Drewett I, et al. The Impact of Trauma Care Systems in Low- and Middle-Income Countries. Annu Rev Public Health 2017;38:507-32.
- WHO. Injuries and Violence: The Facts. World Health Organization 2010.
- Ozgediz D, Riviello R. The “other” neglected diseases in global public health: surgical conditions in sub-Saharan Africa. PLoS Med 2008;5:e121.
- Farmer PE, Kim JY. Surgery and global health: a view from beyond the OR. World J Surg 2008;32:533-6.
- Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015;386:569-624.
- WHO. World Health Assembly Resolution 68.15: Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Sixty-Eighth World Health Assembly 2015.
- Gajewski J, Bijlmakers L, Brugha R. Global Surgery – Informing National Strategies for Scaling Up Surgery in Sub-Saharan Africa. Int J Health Policy Manag 2018;7:481-4.
- Sullivan R, Alatise OI, Anderson BO, et al. Global cancer surgery: delivering safe, affordable, and timely cancer surgery. Lancet Oncol 2015;16:1193-224.