Global Burden of Surgical Illness with Dr. Brian Cameron

” Surgery is the neglected stepchild of Global Health”

Dr. Paul Farmer, Founder of Partners in Health

“Surgery is an indivisible , indispensable part of health care.”

Dr. Jim Kim, President of the World Bank

Dr. Cameron is a pediatric surgeon trained at Queens University and Calgary and has been involved in global health projects in Guyana since the 1990s. Now working at McMaster we were lucky to have him come talk to use on the Global Burden of Surgical disease.

The neglected global burden of surgery is a topic I am familiar with. Last summer I had the opportunity to work with Dr. Hodiae and her NEURONproject which offers online courses for neurosurgery residents in low resource settings. Through this work I learned about the often-overlooked disparity in access to surgical care. The poorest 1/3 of the world’s population receive 3.5% of all surgeries. In addition it is estimated 11-15% of all global DALYs are due to surgical illness, this is greater than the 7-8% estimated for mental illness, another overlooked burden.This continues to be a topic I am concerned with and will be retunring to work with Dr. Hodiae and the NeuronProject for my practicum. This topic is one that the Lancet has recently focused on with a global surgery commission currently taking shape. As such, I was excited to hear Dr. Cameron speak on the burden of global surgical disease.

Dr Cameron started with an overview of what the burden of surgical disease. Dr.Cameron highlighted that surgery is an essential compoenent of any primary care setting. Many may fell that surgery is something that with a strong healthcare system can be prevented, as such previous health care resources should not be divereted towards the expenses of supporting operating room etc.. This idea is flawed, surgery is an essential. In addition to correcting the congenital defects which Dr. camerone mentioned is the main connection people make between surgery and GH, is maternal care such as cesarean sections, dealing with trauma such as broken bones, burns , surgical treatment of infections bacterial or parasitc, not to mention dealing with neurlogic emergencies. Trauma from car accidents was recently highlighted as one of the major killers in the developing world, similarly burns are a major health hazard. Both these conditions may require numerous surgeries to save a person’s life and during the subsequent recovery process. Surgery is not an accessory. Access to surgery could be the difference between death and life or being crippled limiting the ability to work and support a family.

So why is surgery so “neglected” in the words of Dr. Paul Farmer. I agree with the points Dr. Cameron raised.

Surgery is complex: in low resource settings where and who will administer anesthesia? In areas without blood banks, where will the blood for transfusion come from?

Surgical care is not a priority: When people think of global health , TB, AIDs or Malaria come to mind. Disease and problems common to both high income and low resource settings e.g. NCDs, trauma, burns receive less attention .

I want to expand on this point from Dr. Cameron’s. Looking back to times where global health was more appropriately known as International Health, where outsiders dictated what was best for developing nations, disease like TB or malaria grab your attention. They are dramatic and disrupt lives considerably. The burden of chronic disease and surgical illness is more mundane and does not sit with out picture of the developing world. When people hear third world or the developing world they do not think of diabetes and road accidents as these are developed world problems. This is why the global health perspective is important, it breaks down the artificial barrier between us and them.

Surgery is too expensive: the cost of developing surgical capacity, manning ORs, building ORs, equipment etc…is considered prohibitive for low resource settings. Dr. Cameron provided persuasive evidence that low resource nations can not afford to NOT invest in developing surgical capacity. I am biased on this issue but would argue capacity building should start with the human resources, but I will explain my argument at a later point.

The WHO has a table arguing that surgery IS a component of Primary care:

I enjoyed some of the Canadian medical history Dr. Cameron raised. While I was aware of the historic legacy of Norman Bethune, however I was not famailar with the story of Lucille Teasdale, nor the tragic nature of both their deaths.

What attracts me the area of surgery in low resource settings is that it forces capacity building at a local level. Unlike in other areas of Global Health, the expertise for surgery, the resources, the equipment must be on the ground. In contrast many international/gh interventions may side step capacity building providing a pill or treatment for a disease. Treatment is important but in terms of sustainability capacity building is the answer. Providing people with the knowledge and skill set to work in low resource settings , people who understand the context and are committed to change, these are the people who will innovate around surgical care. That is why I view capacity building activities like the NeuronProject as being so important. Surgeons working in low resource settings can be an important source of innovation. There is a history of surgeons creating new tools and procedures to cope with the limited resources they are facing, this is known as value innovation. These advances in care are often adopted in the high resource settings e.g. the Bogota Bag.

At the same time I recognise that providing surgery in low resource settings is very complex and difficult. I can only imagine the frustration for surgeons working in low resources settings, who know that their colleagues elsewhere do not have to battle with the limitations they face daily. I wonder how this scenario plays into the issue of brain drain or brain circulation in the global healthcare workforce. I also wonder how the field of GH can help surgeons in this situation. Perhaps if the mutual benefit of promoting capacity development in resource setting was better recognized globally there would be more effort for collaboration and support for surgeons working in tough settings. This is idealistic but I would argue that is what makes GH a powerful force!

Going back to the NeuronProject, I wonder if mentoring and teaching students in low resource settings is a better model of providing education support than what we currently see. Dr. Cameron mentioned the traditional methods of building surgical capacity such as having short term missions e.g. for repairing cleft palettes or the twinning of hospitals, building missions hospitals or supporting training. Often these models of surgery training involve either an expert going to the low resource setting or sending people from the low resource setting away on fellowships. There are problems to both these formulas. Having a surgeon leave his post in a high resource setting to teach means they are no longer serving their community to home. Medical students who leave their country may decide to never come back. I am not saying these approaches should be stopped only that there needs to be a diversification in methods to support capacity development of health care professionals in low resource settings.

Additional Resources

Bethune Round Table: after talking with Dr. Cameron I have the opportunity to attend the BRT as a member of the social media committee.

Lancet commission on Global Surgery

Unsafe Surgery: A question of gender and economics on the Lancet GH blog

Right to heal a documentary on

Value Innovation: An Important Aspect of Surgical Care http://www.globalizationandhealth.com/content/10/1/1

Required Readings

Farmer PE, Kim JY.

Surgery and global health: a view from beyond the OR.

World J Surg. 2008 Apr;32(4):533-6.

Gosselin RA, Maldonado A, Elder G.

Comparative cost-effectiveness analysis of two MSF surgical trauma centers.