Module 2: Global Burden of Surgical Disease

Recent estimates suggest that 11% of the global burden of disease can be treated with surgery. This total is comprised of injuries (38%), malignancies (19%), congenital anomalies (9%), complications of pregnancy (6%), cataracts (5%) and perinatal conditions (4%). The most surgical disability adjusted life years (DALYs) are in South-East Asia, with 48 million, though Africa has the highest ratio of surgical DALYs per 1,000 people.(1) Though a significant part of the global burden of disease can be treated with surgery, the majority of health facilities in low-income countries do not have the capacity to deliver even the most basic surgical services. It is especially important that surgical services be more widely accessible because future projections suggest a rapid rise in injuries and non-communicable diseases, many of which can be treated by surgery.(2) Moreover, it is important to treat surgical conditions because they tend to preferentially negatively affect the young working population and impoverished patients, through lost days of work and out-of-pocket health expenses.

The burden of disease that injuries and obstetrical complications constitute is particularly significant. Injuries account for approximately 4.3% of total disability-adjusted life years and up to 38% of all surgical DALYs.(3)  Each year, injuries kill more than five million people, accounting for 1 in 10 deaths worldwide. Road traffic accidents, falls, burns and poisoning are the most common types of childhood injuries. (4) For children in Africa who survive the first four years of life, injury becomes the most likely cause of disability, and death. “The available information suggests that surgery patients are responsible for approximately 6-12% of all paediatric admissions in sub-Saharan Africa… the commonest admission diagnoses were injuries, congenital anomalies, and surgical infections.” (5) Regarding obstetrical complications, having access to surgical emergency obstetric care is extremely important in reducing child and maternal mortality. An estimated 500,000 women die each year from pregnancy related complications which required surgical interventions.(6) 99% of maternal deaths occur in low-income countries, and one to two million deaths per year could be prevented through improved trauma care and surgery. “The Disease Control Priorities Project estimated that traumatic conditions and complications of pregnancy account for approximately half of the burden of surgically treated disease in Africa and Southeast Asia.” (7) Unfortunately, the met need for emergency obstetric care (EmOC)is very low in developing countries. For example, it is 31% in Nicaragua and just 13% in Chad.(8)  Though the need for obstetrical operations is reported throughout many countries, only 44% of facilities in Sri Lanka, Mongolia, Tanzania, Afghanistan, Sierra Leone, Liberia, Gambia and São Tomé and Principe were able to offer emergency c-sections. (9) A study on two Tanzanian district hospitals found that between half and two-thirds of women that needed a cesarean section did not have access to the procedure. (10)

The most common types of surgeries that take place vary slightly by country, but tend to include obstetric interventions and hernia repairs. For example, a study on 10 district hospitals in Ghana found that caesarean section was the most common type of major surgical procedure performed, while the most common minor procedure was suturing. (11) A study of 17 surgical programs in 13 countries in Africa, Asia and South America found that 40% of the surgical procedures conducted were obstetric-related, while 14% were trauma related.(12) A study on surgical procedures in Sierra Leone found that the most common types of procedures were cesarean sections, hernia repairs, and appendectomies. (13) Similarly, a study on providers of surgical care in Sudan found that hernia surgery was the most common type, followed by proctologic and gynecologic operations.(14) Though there is a demonstrated need for hernia repairs, unfortunately, only 32% of facilities reported being able to conduct them. (15)

Great Disparities Exist in Access to Surgical Care

Though most of the global burden of surgical disease falls among the world’s poorest, only a small %age of surgical interventions occur in lower income countries. “Global disparities in surgery are staggering, with only 26% of operations performed in poor- and low-health expenditure countries, which account for 70% of the world's population.”(16) Moreover, “it is estimated that there are 234.2 million major surgical procedures performed worldwide annually; however, 30% of the world's population receives 73.6% of these procedures while the poorest third receives only 3.5%.”(17)  A study which examined 56 WHO member states found that reported rates of surgery ranged from 148 per 100,000 people in Ethiopia to 23,369 per 100,000 people in Hungary. Countries that spend less than $100 per person on health care were found to have an estimated rate of major surgery of 295 procedures per 100,000 people per year, whereas those countries which spend more than $1,000 have a rate of 11,110 procedures per 100,000 people per year.(18) One of the main reasons that poorer countries have lower rates of surgery is because they have fewer trained local surgeons. For example, there are five orthopedic surgeons per 100,000 people in high-income countries compared to less than one per million in sub-Saharan countries. “Such data point to the tremendous disparity that exists but also to the potential improvements that could be realized if such inequity was addressed.” (19)

Advanced Pathologies

Because many people in low income countries lack access to basic surgical care, minor surgical pathologies oftentimes develop through time and inattention into potentially lethal conditions. For example, often as the patient has to wait for surgery, cancers will become inoperable, the uterus might rupture from obstructed labor, injury that could have been corrected in a few hours becomes a permanent disability, and cleft palate can remain a life-long affliction rather than a pediatric surgical disease.(20) Fistula is another condition which if not immediately operated upon becomes increasingly disabling and difficult to repair. There are over 2 million women in Africa who live with untreated obstetric fistula.  Since access to basic emergency surgery is lacking, their conditions will most likely grow worse, causing them to become even more disabled. Moreover, when and if they are able to receive care, they will require more resource-intensive surgery.(21)

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Footnotes

(1) Ozgediz, D., Jamison, D., Cherian, M., and McQueen, K. “The burden of surgical conditions and access to surgical care in low- and middle-income countries.” Bulletin of the World Health Organization. 86.8 (2008): 577-656. Accessed on 1 November 2010.

(2) McQueen et. al. “Essential Surgery: Integral to the Right to Health.” Health and Human Rights in Practice. 12.1 (2010): 137-152. Accessed on 13 September 2010.

(3) Ozgediz, D. “Population Health Metrics for Surgery: Effective Coverage of Surgical Services in Low-Income and Middle-Income Countries.” World Journal of Surgery. 33.1 (2009): 1-5. Accessed on 2 November 2010.

(4) Bickler, S., and Rode, H. “Surgical Services for Children in Developing Countries.” Bulletin of the World Health Organization. 80.10 (2002). Accessed on 2 November 2010.

(5) Ibid.

(6) “Emergency and Essential Surgery: the backbone of primary health care.” Accessed on 3 November 2010.

(7) Ozgediz, D. “Population Health Metrics for Surgery: Effective Coverage of Surgical Services in Low-Income and Middle-Income Countries.” World Journal of Surgery. 33.1 (2009): 1-5. Accessed on 2 November 2010.

(8) Ibid.

(9) Kushner, A. “Addressing the Millennium Development Goals From a Surgical Perspective. Essential Surgery and Anesthesia in 8 Low- and Middle- Income Countries.” Archives of Surgery. 145.2 (2010): 154-159. Accessed on 29 October 2010.

(10) Galukande, M. “Essential Surgery at the District Hospital: A Retrospective Descriptive Analysis in Three African Countries.” PLoS. 7.3 (2010). Accessed on 10 November 2010.

(11) Abdullah, F., et. al. “Assessment of Surgical and Obstetrical Care at 10 District Hospitals in Ghana Using On-Site Interviews.” Journal of Surgical Research. (2010). Accessed on 5 November 2010.

(12) Chu, K. “Operative Mortality in Resource-Limited Settings.” Arch Surg. 145.8 (2010): 721-725. Accessed on 4 November 2010.

(13) Kingham, T., et. al. “Quantifying Surgical Capacity in Sierra Leone A Guide For Improving Surgical Care.” Arch Surg. 144.2 (2009); 122-127. Accessed on 4 November 2010.

(14) Meo, G., et. al. “Rural Surgery in Southern Sudan.” World Journal of Surgery. 30 (2006): 495-504. Accessed on 4 November 2010.

(15) Kushner, A. “Addressing the Millennium Development Goals From a Surgical Perspective. Essential Surgery and Anesthesia in 8 Low- and Middle- Income Countries.” Archives of Surgery. 145.2 (2010): 154-159. Accessed on 29 October 2010.

(16) Ozgediz, D. “Voluntarism and the Global Unmet Need for Surgery.” Archives of Surgery. 144.3 (2009). Accessed on 29 October 2010.

(17) Khalil, I. “Comment on ‘Addressing the Milleniumm Development Goals From a Surgical Perspective.’” Surgical Care Delivery and World Health. 145.2 (2010): 160. Accessed on 29 October 2010.

(18) Weiser, T., et. al. “An Estimation of the Global Volume of Surgery: A Modelling Strategy Based on Available Data.” Lancet. 372. (2008): 139-44. Accessed on 1 November 2010.

(19) Ozgediz, D. “Population Health Metrics for Surgery: Effective Coverage of Surgical Services in Low-Income and Middle-Income Countries.” World Journal of Surgery. 33.1 (2009): 1-5. Accessed on 2 November 2010.

(20) Luboga, S., Galukande, M., and Ozgediz, D. “Recasting the role of the surgeon in Uganda: a proposal to maximize the impact of surgery on public health.” Tropical Medicine and International Health. 14.6 (2009): 604-608. Accessed on 8 November 2010.

(21) Farmer, P., and Kim, J. “Surgery and Global Health: A View from Beyond the OR.” World J Surgery. 32. (2008): 533-536. Accessed on 2 November 2010.