Why We Need to Address Surgery in Low-Resource Countries ?

Surgery remains grossly neglected in global health. This particularly affects low-resource settings with weak surgical health systems. ‘Global surgery’ is the term now adopted to describe the rapidly developing field seeking to address this, although recognition of this emerging multidisciplinary area is still evolving. To help define this interface between surgery, anaesthesia, and public health, a comprehensive new review was published in BMJ Global Health lately. It defined global surgery as “the enterprise of providing improved and equitable surgical care to the world’s population, with its core tenets as the issues of need, access, and quality”.

The article reviews current literature to update and quantify the current evidence underlying the core principles around global surgery to arrive at the definition. It is  however also important to remember what such definitions  means to patients and health workers who face these challenges every-day.

Kinshasa or “Kin la belle” (Beautiful Kin) as she is fondly called is a city of paradoxes and inequities. Today I was reminded of this as I pass through Pakadjuma, one of Kin’s poorest district. All I see are derelict and frail houses. Non-biodegradable plastics canopy the sandy ground and contrast with the filth in the artificially created gutters. Children play football barefoot and name themselves after their favourite players – they imagine themselves scoring a goal at one of Europe’s big stadia. In all this misery they are happy!

I lose myself in my thoughts trying to understand how and why they are happy. My workplace is in Kin’s fanciest neighbourhood, Gombé. My hospital, Ngaliema Reference Hospital, is contiguous with the presidency buildings and within walking distance to Kin’s finest hotels: Pullman and Kempinsky. Everything in Gombé is clean, the gutters functional, the buildings a mix of old and contemporary architecture, children playing on the streets  and yet many do not seem happy.

Heading back home after a busy day, I stopped by at a nearby private hospital. As I was about to leave, I heard a loud cry and I instinctively ran towards it . I found a woman with a boy in her hands screaming at the top of her lungs. The boy had a head larger than normal, his eyes were setting and he was unresponsive – his ventriculo-peritoneal shunt had failed and he had developed acute hydrocephalus. My boss asked the patient to be transferred to our hospital. The woman was flustered, inconsolable and insisted on accompanying her grandchild in the ambulance. During the ride she told me he had been born with hydrocephalus, and was very smart and lively. The family was from Mbandaka, more than 2 hours by flight from to Kinshasa. However once in Kinshasa they are now being taken to “a big private hospital”.

Once we reached Ngaliéma our team ordered a head CT scan and routine lab tests. We proceeded with surgery, which was straightforward and successful. The family paid for everything in cash upfront!  While this story has a happy ending, it is a nightmare for the other 84 million Congolese who cannot afford to fly to Kinshasa, cannot rely on serendipity to meet a neurosurgical team, and cannot pay for huge out-of-pocket expenditure.

The Lancet Commission for Global Surgery described three delays to surgical care access: delays in seeking, reaching and receiving surgical care. Putting this into my local context, the Democratic Republic of Congo’s (DRC) surface area is 10 times that of the United Kingdom. Yet DRC has only neurosurgical centers at  Kinshasa, Bukavu and Lubumbashi. Unfortunately, the unmet needs are not limited to  just neurosurgery . It extends to anaesthesia, obstetrics, trauma, paediatric surgery, oncologic surgery, cardiac surgery and plastic surgery. As a result, rural patients travel long distances to get specialised surgical care in the cities.

Those who get to the hospital face the greatest challenge of all, out-of-pocket expenditures. It is estimated that 33 million face catastrophic expenditures due to surgical care. DRC has no universal health coverage so patients and their families bear the costs of their treatment. With 63.9% of the population living below the poverty line, health care expenditures represent a major threat to both families and the nation. Poverty and surgical diseases feed off of each other leading the nation into a quicksand of underdevelopment. To break this vicious cycle, DRC and other low- and middle-income countries should invest in global surgery.

Health is a fundamental right and there is no health care without surgical, obstetric, anaesthetic and trauma care. Discriminatory surgical care access exacerbates social inequities and restricts national development. Therefore, access to surgical care should not depend on our location, our social status or sheer luck.

About the author:

Ulrick Sidney is a Research Associate at the Program in Global Surgery and Social Change, Harvard Medical School and the Project Coordinator of the World Federation of Neurosurgical Societies’ Neurosurgical Workforce Mapping Project.

 

Competing interests. I have read and understood BMJ policy on declaration of interests and declare that I have no relevant conflicts of interests to declare.

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