Time for New Revolutions in Global Health Care

Necessity dictated that I learn rapidly, so I was taught by an operating assistant. Using a small generator to provide light and suction, ether for anesthesia and nursing aids, I was able to carry out many life-saving C- sections, often in the dead of night.
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Non-communicable diseases, trauma and maternal death have now assumed a significant part of the disease burden in low and middle-income countries (LMICs), yet these issues are only recently gaining a foothold in the global health dialogue, which has previously concentrated on communicable diseases. A significant number of these conditions, including cancer, trauma and obstetric complications cause needless loss of life, decreased productivity and poor economic development, yet all could be treated with simple, inexpensive surgical procedures. Essential surgeries can be available, even in the most basic of conditions, with the adoption of three simple but radical innovations: power-independent anesthesia, instrument sterilization that does not require heat or power and task shifting (surgery by non-surgeons).

It is estimated that two billion people worldwide do not have access to essential surgery. Although a consensus is building around the critical need for essential surgery in LMICs, the barriers to surgery in resource-limited settings have not been concretely defined. Part of this failure is due to a lingering perception that modern surgery is too costly and technologically advanced for the developing world. It is time to debunk this perception and acknowledge that surgery is an essential part of primary care and should be guaranteed to all. The history of how surgery developed from a crude, last-ditch effort into routine medical practice reveals the basic necessities for safe surgery.

The introductions of anesthesia, sterilization and academy-trained surgeons were the three revolutions of modern surgery, but this history reflects progress that has prioritized a small portion of the world's population. Complexity and technological advancement have been celebrated, leading to innovations with increasingly great resource requirements and as a result, surgery now allows physicians to perform previously unthinkable medical feats. The other side of the coin is that the most basic surgical interventions still remain inaccessible for much of the world, and the increasing specialization of surgery encourages the perception in developing countries that it falls within the purview of the referral hospital. It is time for the medical community to promote surgical innovation that addresses the realities of healthcare delivery in LMICs, such as the lack of electricity, plus an extreme shortage of qualified surgeons.

The use of anesthesia during surgery was first demonstrated in Boston in 1846, when Dr. William Morton used ether to put his patient under while removing a tumor from the jaw. Within months, surgeons throughout Europe and the United States were using ether to anesthetize patients during surgery, allowing freedom from pain and longer, more precise procedures. Surgery then became a much more common intervention, but people continued to die from infections. It was not until sterilization developed that surgery could become a truly significant intervention.

Adoption of sterilization for surgery was a slow process. When Joseph Lister introduced his carbolic acid spray for disinfection in 1867, the causes of infection were not commonly understood. However when germ theory became the accepted dogma in medicine, and Louis Pasteur discovered that very high temperatures could kill microorganisms, sterile medical care became the norm. Hence with the combined implementation of anesthesia and sterilization, surgery itself was no longer a life-threatening undertaking. Procedures were then able to increase in precision and duration, elevating surgery from option of last resort to being an important medical tool. Previously relegated to technicians who had not attended medical school, surgery was integrated into a rigorous physician training and certification system resulting in the title of "surgeon" being reserved only for those who had completed many years of training and specialized practice.

These revolutions account for surgery as we know it in the developed world, but where do they leave those who receive treatment at a health center with no electricity, or who live in a country with only nine fully qualified surgeons? Currently available methods of sterilization and anesthesia depend upon electricity, leaving surgical care in many LMICs stuck in the beginning of the 19th century. Additionally, many of these same countries suffer from an extreme deficit of surgeons, so the accepted norm of using a highly trained doctor to carry out surgery is not practical. Innovation must tackle these issues, so that life-saving procedures can be available to all.

We have some good news. Technologies for electricity-independent anesthesia and sterilization have been developed and are being introduced to the places where the need is most acute. Certain countries have begun to train non-physician clinicians (NPCs) to perform specific surgical procedures, a practice known in the global health world as "task shifting." The evidence shows that the outcomes for surgeries performed by NPCs are comparable to those performed by surgeons, yet the stigma against non-surgeons performing surgery persists. It is time for such elitist mindsets to change, and it is time for surgical innovations for low-resource settings to be prioritized and efficiently implemented wherever needed. We know the obstacles to essential surgery, and we know the solutions; now it is time to take action.

Dr. Clarke's Ugandan Perspective:

I have worked in a resource poor country (Uganda) for over 25 years, during which time I have observed the gap between western medicine and healthcare in Africa increase. Medicine in developed countries has become increasingly sophisticated and high-tech, while many parts of Africa have either stood still or gone backwards. Either way, in many rural areas the availability of relatively basic surgical procedures appears to be decreasing, where surgery is now seen as the domain of the referral hospital. However this need not be the case. I was not a general surgeon when I arrived in a rural area in Uganda 25 years ago. I had trained as a family doctor and could not even carry out a caesarian section. But necessity dictated that I learn rapidly, so I was taught by an operating assistant, who had no formal training in medicine, but a wide hands-on experience in surgery. Using a small generator to provide light and suction, ether for anesthesia, and nursing aids as scrub nurses, I was able to carry out many life-saving C- sections, often in the dead of night. The sad thing is that 25 years later, with all the sophisticated advances in medicine and the emphasis on increasing specialization, the gap in what is available in basic settings, to what we take for granted in the West, appears to have grown.

Sometimes simple situations also need simple solutions -- power free anesthesia, power free sterilization and task shifting can make life-saving procedures available to many.

Research and editorial assistance was provided by Ariel Trilling.