Q: How big is the current gap in access to basic surgical care worldwide?
Weiser: There are at least 143 million additional operations needed to meet the basic disease burden and surgical conditions affecting people living in low- and middle-income countries, or LMICs. Of the 313 million operations performed in 2012, only 6 percent were performed in LMICs, where over a third the world’s population lives.
There are tremendous disparities in access to and provision of care, but bigger still is the variability in outcomes following surgery. For example, death rates for cesarean section are orders of magnitude higher in poorly resourced settings. Such death rates would be unacceptable in the U.S., yet this is a fact of life for most of the world. I suspect the variability in access, provision and outcomes of care are as high, if not higher, within countries as between them, indicating that many places could quickly improve if the right policies were implemented and investments made.
Q: Why has it taken so long for global surgery to gain attention on the public health agenda?
Weiser: The biggest barrier has been a complete lack of data. Surgery is a therapy, not a disease, and does not fit nicely into a box that can generate interest and support. Most public health priorities focus on a disease entity, or specific health condition, and use vertical programs to address the problem.
Many of these programs are developed in parallel to a poorly functioning health system. Vaccines are a great example. Delivering vaccinations to a population requires a cadre of community workers, training, materials and a cold chain — a supply chain in which a product, in this case vaccines, can be maintained at a certain temperature or temperature range while being transported. Much of this can be done with the support of the health system and ministry, but vaccination campaigns do not necessarily strengthen the health system.
Surgery, however, is too complex to be undertaken without a strong health-delivery program. It requires a strong and continuous supply chain, highly technical skills and ongoing training, and intensive management to organize such services. It was previously considered too expensive and cost-ineffective, although there were no data to support such suppositions. In fact, we now know investing in surgery is incredibly cost-effective, and although building surgical capacity from nothing would require substantial capital investment, the returns to the health system and the overall health of the population would be tremendous.
Q: Can countries afford to invest in global surgery?
Weiser: The Lancet Commission estimates that over the next 15 years, global output will lose $20 trillion in productivity due to surgical conditions. Of this loss, well over half, or $12 trillion, will come from LMICs with low surgical rates. To bring LMICs up to par with their assessed needs, however, would require an investment of some $300-$400 billion over the same time period. While this investment seems huge, it is actually a good purchase when measured against a $12 trillion loss in these same countries.
There are additional gains that were not included in the commission’s assessment, making this appraisal a likely underestimate. As I mentioned, investing in surgical capacity, infrastructure and skills are a foundational component of strengthening health systems more generally, and would yield additional health savings in other, nonsurgical diseases. For example, improvements in supply chains and resource management, which are necessary to the scale-up of surgical interventions, will have profound effects not just on the health system, but in many other nonmedical sectors. Strengthening surgical capacity is, in my opinion, health-system strengthening.
Q: What impact do you hope these findings will have in shaping public health policy?
Weiser: First and foremost is the pulling back of the curtain on what the state of surgery is around the world. Understanding the disparities in access to and outcomes of care, the health and economic consequences, and the effects of improved delivery, safety and quality of surgical care are all essential if we are to generate interest in the issues and commitments to making care better, safer and more equitable.
I hope that these findings and the new data presented in the commission report will increase attention and awareness of the vital role surgical care plays in a health system. Ideally we will see increased leadership from organizations like the WHO and the World Bank in the form of attempts to standardize data collection, identify high-performing health systems, publicize successful programs and promote their adoption and replication in other health settings, and support improved investments in surgical capacity and quality improvement as a way to strengthen the health system more generally.
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