Global Surgery: Myths and Realities

Whether it's grabbed off the bar in Montana, Washington D.C., or Moscow, every Starbucks Frappuccino tastes just as sweet as the next. When you enter past that ubiquitous green Siren, you could be anywhere in the world. This is the key to Starbucks' success: consistent, reliable quality. They ensure every employee has the training and supplies required to triumph during the morning rush. In a recent piece for The New Yorker, writer and surgeon Atul Gawande suggested that important lessons for the U.S. healthcare system lie within the success of large restaurant chains. The food and beverage industry offers numerous examples of across-the-board standardization to ensure quality and affordability. There's no reason such lessons should not be applied to global health as well.

That morning Starbucks jolt might feel vital, but what the world really needs is consistent, quality surgical services in developing countries. In communities around the world, lack of training and supplies mean there is little to no surgical treatment available for injuries, maternal complications, cancer, congenital malformations, and emergencies like appendicitis. Injuries, intentional and accidental, cause more deaths in the developing world than HIV, TB, and malaria combined, yet shockingly little is being done. No global strategy has been instituted to address the deficiencies in infrastructure and sterile supplies. No global framework has been approved to ensure efficient, quality surgical training. And to date, global health funders, such as USAID, the World Bank, and the Gate's Foundation, have not been willing to specifically finance surgical services.

The word 'surgery' conjures images of complicated operations involving the heart, brain, or other vital organ. Most 'essential surgeries' are simple, affordable procedures that prevent permanent disability and life threatening complications. This includes treating wounds, removing foreign bodies, draining abscesses, and obstetric procedures including caesarian sections. These types of surgeries will inevitably be performed no matter the conditions, but without proper training and the necessary equipment they can often lead to dangerous complications, such as life threatening infections. To propel meaningful change, we need to bust some of the myths that, I am sure, have already clouded your view.

Myth: Surgery is complicated.

Reality: Some surgery is complicated. But in developing countries with few skilled surgeons, well-trained health workers who did not attend medical school can successfully perform many types of operations. Tanzania, Mozambique, and Malawi all train health officers to become assistant medical officers (AMOs) who receive surgical training without first receiving a medical degree. In portions of Tanzania, 75% of all operations are performed by AMOs.

Myth: Surgery should only be done in high-level hospitals.

Reality: Distance seriously hinders access to surgical care. Ninety percent of women who need an emergency cesarean section in Niger do not receive appropriate care because the hospital is just too far away. And over half of those requiring surgery did not go to the hospital - even when emergency transport was available - because the cost of transportation was just too high. Surgery can only be effective if patients can reach it. A trained professional, basic supplies, and an effective method of instrument sterilization are often all that is necessary to perform life-saving procedures.

Myth: Surgery isn't cost-effective.

Reality: Basic surgery can be as cost-effective as the measles vaccine. Due to the low infrastructure cost and high disease burden, surgeries performed in the district hospitals of Sub-Saharan Africa and South Asia are some of the most cost-effective operations in the world. One insightful tool for measuring impact is DALY (Disability-Adjusted Life Years), which determines the number of healthy years lost to disability or premature death. The cost of saving one healthy year of one person's life with surgery is only $33 in Sub-Saharan Africa or $38 in South Asia. But it isn't just about saving peoples lives; it is about improving the quality of life. The cost of saving a person in India from a year of blindness with cataract surgery is less than $25.

Reliable, effective surgical care for all can deliver extremely high social and economic returns. It is time for the global community to help make this a reality by designing a clear framework for the infrastructure and personnel needed to deliver essential surgical interventions currently out of reach to millions of men, women and children in the developing world. To be successful, such change requires easily accessible, sterile surgery, performed by well-trained individuals equipped with the necessary supplies. Starbucks has figured out how to sell the same Frappuccino to customers all over the planet. Surely, with a bit of investment and innovation, we can also find a way to bring safe, affordable surgery to those who need it the world over.

Editorial assistance was provided by Isabelle Winer from Eniware.