Global Surgery: A Bold Plan for Access, Equity

A new view of surgical care

In a 2008 commentary in the World Journal of Surgery, global health pioneers Paul Farmer and Jim Kim called surgery “the neglected stepchild of global health.” Farmer and Kim, both infectious disease doctors and at different times chair of the HMS Department of Global Health and Social Medicine, highlighted the importance of surgical care in treating patients with all kinds of diseases, noting that surgical capacity was a necessary component of any functioning health system.

At the time of the commentary’s publication, the prevailing belief was that surgical care was prohibitively expensive, that conditions requiring surgical treatment were a small fraction of the global disease burden, and that surgery didn’t have a place in “serious” discussions of global, public, or population health.

One of the early converts to Farmer and Kim’s provocative view was PGSSC founding director John Meara, a craniofacial surgeon and HMS professor of surgery at Boston Children’s Hospital. When Meara launched a global surgery fellowship at HMS in 2008, inspired by working alongside Farmer in Haiti, HMS was one of the few places where people were starting to focus on the importance of surgery for health equity.

This all changed with a sobering 2015 report from the Lancet Commission. It calculated a staggeringly widespread need for surgical care across life span and across all areas. It quantified the human toll, loss of life, and decreased economic productivity caused by lack of access to surgery. It also mapped a bold plan to bring surgical care to all. Meara, Farmer, and Kim, who was also president of the World Bank at the time, were among the commission’s leaders, and many faculty and fellows in the PGSSC contributed to the research behind the report.

The World Health Organization now recognizes surgical care as an essential component of universal health coverage and dozens of nations have crafted national plans to build surgical capacity and integrate surgical care into national health systems.

“There’s been a massive shift in how global surgery is seen,” Meara said. “The question now isn’t should we do this or could we do this, it’s how can we get it done.”

One key part of the PGSSC has been supporting national surgical, obstetric, and anesthesia planning processes. The program collaborated with the United Nations Institute of Training and Research to create a manual and other resources for these processes and provided training and guidance to dozens of nations as they set their agendas for surgery. Many of them are beginning to implement their plans, assess their progress, and fine-tune next steps.

Faculty and fellows from the PGSSC recently helped complete a plan for Ecuador — the first national surgery plan in the Americas.

Working with Ecuador helped the PGSSC team develop relations around the region. In particular, collaborating with Alfredo Borrero, a neurosurgeon who was vice president of Ecuador when the process began, has created a great feeling of momentum in the region, said Pablo Tarsicio Uribe Leitz, an HMS instructor in surgery at Brigham and Women’s Hospital who helped lead the Ecuador project.

Leaders in countries such as Paraguay, Honduras, and Brazil have expressed interest in participating and are advocating to make surgical capacity a regional priority at the Pan American Health Organization, he said.

Uribe Leitz also noted that in addition to cultivating relationships with political leaders to generate momentum, it is critical to work closely with local champions for surgical equity who work outside the political realm, since doing can help maintain momentum when political leaders change. While Borrero is no longer vice president, there are surgeons and administrators in place across Ecuador who are dedicated to continuing the work, including Borrero himself, through the creation of a foundation to continue improving access to surgery in Ecuador and the surrounding region.

Building systems, building community

Other regional associations are taking on surgery, including the Pan-African Surgical Health Care Forum. Many HMS faculty members and former PGSSC fellows are helping lead these processes by gathering data about surgical capacity, implementing and studying clinical and community health systems, and creating space for studying, researching, and doing work that focuses on equity in access to surgery.

PGSSC director Robert Riviello, chair of the surgery department at the University of Global Health Equity in Rwanda (UGHE), is participating in the pan-African forum as a representative of UGHE. Regional coordination is an important step forward, he said, and an opportunity to share lessons learned from a decade of national planning work.

Since PGSSC’s founding, more than 100 fellows and research collaborators have completed two-year terms of mentored research, preparing them for leadership roles in global surgery. Many former fellows have assumed prominent leadership positions in global surgery within the program, at HMS-affiliated hospitals, and at other institutions.

For example, Barnabas Alayande, a general surgeon and assistant professor of surgery at the UGHE, leads efforts in surgical education, research, innovation, and improvisation.

When the Lancet commission launched, Kee Park, HMS lecturer on global health and social medicine, part-time, was teaching neurosurgery in Cambodia. The commission helped change his perspective on his work.

“I realized that I wasn’t going to be able to solve this massive public health challenge from the clinic or the classroom,” Park said.

He met Meara and Farmer, and they invited him to come to HMS as a global surgery fellow. He started working on national surgery plans, building networks with global surgery leaders, and diagnosing challenges that arose. Park is currently the PGSSC’s director of policy and advocacy.

This summer, Park will start a new three-year posting, paid for by the U.S. National Cancer Institute, that will enable him to work directly with WHO headquarters and regional and country offices, national leaders from UN member states, representatives of ministries of health, academic partners, private organizations, and entrepreneurs.

“It’s a complex problem; we must find creative solutions,” Park said. “But we’re on our way now, and we're not going to stop until there are no more unnecessary, preventable deaths.”

The way forward

“What’s promising about the future of global health is that there are ever-increasing numbers of young people committed to seeing change for the better for vulnerable populations,” Riviello said.

One of the things that’s empowering young people is the shared sense of belonging that has arisen as the idea of global surgery has spread. This pull is perhaps strongest in academic institutions. Most top U.S. academic medical centers now have at least one person who is active in the field of global surgery, and many have related fellowships and programs.

But more needs to be done to make sure that the growing global surgery community is welcoming for the many different kinds of people who make surgery possible — not just surgeons and PhDs, several program leaders said.

“We have to create space in the field for physical therapists, nurses, and the people who work on supply chain,” said Hedt-Gauthier, co-director of research for the PGSSC.

Just as surgery is a crucial part of almost every kind of health care — maternal health, oncology, trauma — there are many elements of health care, aside from what happens in the operating room, that are crucial to successful surgical care.

“We don’t want to just optimize surgical procedures. We want to optimize all the necessary systems for the health of the patient who is having the operation,” Hedt-Gauthier said.

Nakul Raykar, HMS assistant professor of surgery at Brigham and Women’s Hospital and the current director of the PGSSC fellowship program, was a fellow himself in 2012 and 2013 and a lead research fellow on the Lancet commission.

The commission has made great strides in galvanizing the community, he said, but in terms of providing better surgical care, there’s still a lot more to to do.

“There are still billions without access to surgery, and far too many who face crushing bankruptcy when they are able to access care,” Raykar said.

To make significant progress on these long-term goals, it’s important to find ways to address the most immediate needs of frontline workers in places bereft of surgical care, Raykar said. If you go to a rural clinic and talk about overarching plans that were mostly developed by people at big urban universities and hospitals, there’s a disconnect, he said.

“We say, workforce, finance, and information systems, and people working on surgery in a rural clinic say, that’s fine, but we really need blood for our patients,” he said.

Raykar and his colleagues heard this so often that they started a coalition to eliminate the world’s blood deserts. Going forward, the PGSSC is also planning to build a cross-cutting, collaborative approach to bolstering blood supply that will involve faculty and fellows from the whole team.

Bringing hope to life

Since Birra’s death, Boatin has remained dedicated to making childbirth safer for mothers and babies. Her latest project leverages the digital communications revolution to study the use of wearable vital sign monitors in hospitals in Uganda.

Hedt-Gauthier’s team, meanwhile, is testing a new, AI-enabled mobile app that can flag women at risk for surgical site infections following caesarian sections. The project is underway in Rwanda, but Hedt-Gauthier and her colleagues are already thinking about what would be needed to re-train the algorithm to work with people with other skin colors in places like Central America.

Other PGSSC members are developing, measuring, and improving clinical and policy interventions locally, nationally, and globally. For instance, Michelle Joseph, instructor in global health and social medicine in the Blavatnik Institute at HMS, is working to improve integration between military and civilian health systems to help countries prepare better for natural disasters and other health emergencies. And Raykar is using military medical methods to alleviate community blood shortages like the one that took Birra’s life.

With time, PGSSC faculty could facilitate a future where everyone, everywhere, has access to safe surgical care when they need it.

“Surgical care touches people at all stages of life, from before birth to the end of life,” Riviello said. “Health care isn’t a choice between screen, prevent, treat, or palliate. It’s got to be all of the above.”