Difficult Access To Surgical Care

FATIMA lives in Sudan. She went into labour at the age of 16, ten years ago, but by the time she was taken to hospital, the baby was dead. Fatima developed an obstetric fistula during the difficult delivery and started leaking urine. Her husband divorced her, leaving Fatima emotionally shattered by the loss of her husband and first born child.

Few of us in Europe or North America have heard of obstetric fistula, but it is a serious problem in the world’s poorest countries, where too many mothers give birth without any medical help. In these cases, if a woman’s labour becomes obstructed, she will endure days of painful, prolonged labour. Her baby is unlikely to survive, and, if the woman survives, her body is literally broken by childbirth. An obstetric fistula is a hole between the vagina and rectum or bladder that is caused by prolonged obstructed labour, leaving a woman incontinent with urine or faeces or both. Uncontrollably leaking bodily wastes, these women are often shunned by their families and communities who cannot tolerate the unpleasant smell. And the numbers are staggering. At least two million women worldwide are currently suffering from this life-changing, but treatable condition.

Obstetric fistula repair surgery could help them, but they are among the two-thirds of the world’s population that has no access to safe and affordable surgery. The vast majority live out their lives with damaged bladders or bowels, and with incontinence and rejection.

 

Staggering figures

 

When we talk about global health, most people think of issues such as vaccination, maternal care, sanitation, and malaria control. It is not usually associated with surgery. But consider the woman who dies in childbirth because she can’t reach a clinic that performs caesarean sections, or the man out of work because he can’t afford cataract surgery to restore his vision, or the child whose life is cut short by an injury that local healthcare workers don’t have the training to repair. 

In April this year the Lancet Commission on Global Surgery reported that essential surgical and anaesthesia care is being denied to more than four billion people around the world. A panel of 25 medical experts in the fields of surgery and anaesthesia concluded that two-thirds of the world’s population lack access to “safe and affordable surgery” and that the deficiencies in care will have dire effects on human health and welfare. The 25 experts spent a year and a half gathering evidence and testimony from healthcare workers and patients from 196 countries as part of this report. They examined access to surgical services in four areas: timeliness, surgical capacity, safety, and affordability. Findings were that surgical and anaesthesia care in many low-income and middle-income countries has been largely neglected. “We want surgery to be part of the discourse on global health, and we want surgery integrated into the discussions about how you build health systems,” said John Meara, one of three commission co-chairs who is an associate professor of surgery at Boston Children’s Hospital in addition to holding a professorship in global surgery at Harvard.

 

Catastrophic expenditure

 

Treatment for surgical conditions, such as obstetric fistula, and a broad range of conditions that kill, such as appendicitis, fractures and breast cancer, remains out of reach for the majority of the world’s population. This results in loss of life and reduced welfare for millions of people, and stunts economic development of countries. A lack of investment in surgery will contribute to losses in economic productivity, estimated cumulatively at 12.3 trillion US dollars between 2015 and 2030. It was noted that it is largely the “poor, marginalised and rural” who face too many hurdles to get access to it. Across the world, 33 million individuals each year face “catastrophic health expenditure” on surgery and anesthesia. “A quarter of people who have a surgical procedure will incur financial catastrophe as a result of seeking care”. Another 48 million are pushed into poverty because they need to pay for things like transport and food while getting to the hospital.

The study found that 93 percent of people in sub-Saharan Africa cannot obtain basic surgical care. One of the study’s authors, Andy Leather, director of the King’s Centre for Global Health in London, described the situation as “outrageous”. He said, “people are dying and living with disabilities that could be avoided if they had good surgical treatment, and more and more people are being pushed into poverty trying to access surgical care”. In low-income and middle-income countries many patients will not receive standard ‘Bellwether Procedures’ such as laparotomy, treatment of open fractures, or caesarean delivery. Many easily treatable conditions become diseases with high fatality rates.

 

Urban elite

 

The Lancet, an eminent medical journal based in London, formed the commission in 2013 when a small group of surgeons decided to champion an in-depth look at surgery around the world. The commissioners worked with collaborators from more than 110 countries to produce the report. The Lancet Commission on Global Surgery outlines what is needed to achieve global surgical goals, and quantifies the costs of failure if these essential services are not provided.

Andy Leather says, “There’s a myth there isn’t a burden of surgical disease, that it’s too costly and it’s just for the urban elite”. Doctors deal with, broadly speaking, either surgical or medical conditions, and we hear more about the burden of disease from the latter. Yet conditions that could have been treated with surgery accounted for a total of 16.9 million deaths in 2010, the journal found – which was just under a third (32.9 percent) of all deaths that year. This surpasses the number of deaths from HIV/AIDS, TB and malaria combined.

 

Costs of inaction

 

Historically, global surgery has been most identified with medical missions – teams of surgeons who travel to resource-poor areas to perform procedures like cleft lip and palate repair or cataract surgery, which local people can’t otherwise afford. Such intermittent missions have saved lives and improved the health of many patients, but they have also been critiqued for not offering a lasting solution to the larger problems of healthcare delivery in those areas.

The Lancet experts call for a global investment of $420 billion by 2030, an amount the commission says would give acceptable levels of access to surgery in those countries that have the worst availability. They believe this would be an achievable cost “far outweighed by the devastating economic cost to countries, communities, and families incurred by the current global shortfall in access to surgery”. A key challenge is training enough surgeons, anaesthetists and obstetricians. In higher income countries such as the UK, there are around 35 surgical specialists per 100,000 people, whereas in Bangladesh there are 1.7 per 100,000 population. John Meara, a professor in global surgery at Harvard Medical School, suggests that, “although the scale-up costs are large, the costs of inaction are higher, and will accumulate progressively with delay”. He feels the idea that the costs of providing safe and accessible surgery put it beyond the reach of any but the richest countries is a “misconception”.

 

Sustainable development

 

Remarkable gains have been made in global health in the past 25 years, but progress has not been uniform. Mortality and morbidity from common conditions needing surgery have grown in the world’s poorest regions, both in real terms and relative to other health gains. At the same time, development of safe, essential, life-saving surgical and anaesthesia care in low-income and middle-income countries has stagnated or regressed. In the absence of surgical care, case-fatality rates are high for common, easily treatable conditions including appendicitis, hernia, fractures, obstructed labour, congenital anomalies, and breast and cervical cancer.

Yet, as the global health community continues to support the advancement of universal health coverage, increasing access to surgical services will play a central role in ensuring health care for all. While it is true that a culture of surgery safety in high-income countries is not mirrored by surgery conditions in low-income countries, the report felt that neglecting to engage because of safety concerns is not a solution. The Lancet report included success stories about partnerships that have improved surgical care in Haiti, Mongolia, Uganda, and elsewhere. The commission is now working with the Republic of Zambia to begin assessing that nation’s surgical capabilities, based on the approach outlined in the report.

 

Integral component

 

The purpose of The Lancet Commission on Global Surgery was to embed surgery within the global health agenda, catalysing political change, and defining solutions for provision of quality surgical and anesthesia care for all. Surgery, the report said, is an “indivisible, indispensable part of health care” and “should be an integral component of a national health system in countries at all levels of development”. As the global community finalises the international Sustainable Development Goals in September, which includes health targets, perhaps better access to surgery may rise up the global agenda.