Vector Volume 11 Issue 1 - 2017

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Without sufficient public funding or health insurance, access to surgical services depends on the ability of patients and their family to pay. [3] High death rates for surgically treatable conditions in LMICs are often due the financial barriers of accessing surgical care. Thus affordability, and not necessarily availability, of treatment is a major focus. Surgically treatable causes of disease account for 28-32% of the global burden of disease; yet five billion people do not have access to the surgical care they need.[4] There is a common misconception that surgical treatment of these conditions is expensive and not cost-effective. Beyond the incredible impact certain basic surgeries, including caesarean sections and hernia repairs, can have on an individual’s quality of life, their overall monetary cost over time is comparable to other global health initiatives. The cost per DALY averted for basic surgeries is low in LMICs, in both small and large hospitals. Examples include emergency caesarean sections ($18 USD), elective inguinal hernia repair ($12.88 USD), and cleft lip repair ($15.44 USD).[5] In contrast, other widely implemented public health initiatives can cost much more: oral rehydration therapy can cost over $1,000 USD per DALY averted, and HIV HAART therapy can cost over $900 USD per DALY averted.[5] Beyond economic measures, lack of access to treatment of surgically treatable diseases has a major impact on the lives of patients, their families, and their communities. A condition as easily addressed as a strangulated hernia can be life-threatening to an otherwise healthy adult. Such a loss of life or work productivity can have devastating impacts not only on the patient, but also on those who financially depend on them. Surgery in low and middle income countries In the past, the impact of surgical diseases has been vastly underestimated by global Surgically treatable causes of disease account for 28- 32% of the global burden of disease; yet five billion people do not have access to the surgical care they need.[4] health experts, leading to its absence in the Sustainable Development Goals (SDGs). However, since the establishment of the LCoGS in 2015, there has been a shift in this paradigm. With 16.9 million annual deaths (32.9% of all deaths) attributed to surgical conditions, the total burden far outweighs that of tuberculosis (TB), HIV/AIDS and malaria combined.[4] This is because easily treatable surgical diseases such as open fractures and obstructed labour cause significant morbidity and mortality due to lack of access to safe surgical care. The LCoGS sheds light on the startling paucity of surgeries performed in LMICs. It found that a disproportionately low number of surgeries are performed in LMICs compared to the population size. A third of the world’s poorest population resides in LMICs, and yet only 6% of all surgical procedures worldwide are performed in these countries.[4] An additional 143 million surgical procedures are required annually to overcome this present need. Failure to address such basic health and surgical needs can potentially endanger the economic progress of these countries. This is particularly pertinent given the growing population and problem of uneven healthcare access in LMICs. Each year, 33 million individuals worldwide face immense expenditures due to out-of-pocket payment of medical and surgical costs, which can push them into poverty.[4] The LCoGS found that workforce losses attributable to surgical conditions reduce GDP growth by up to 2%, particularly affecting growing nations. If no further is taken to address surgical needs in LMICs, it is estimated that the global economic loss in terms of international GDP could soar up to $12.3 trillion USD from 2015 to 2030.[4] These figures are alarming, and it is of utmost importance to recognise that these are not merely numbers and statistics, but that they represent real people affected every day. What must be stressed is that although the costs of 23
providing surgery are high, investing in surgical services in LMICs is affordable, saves lives, and promotes economic growth.[4] To improve the current conditions, there is a great need to gather data, identify gaps in data regarding surgical access, funding and resources, and monitor progress. Global surgery in action Advocacy in recent years has demonstrated new potential for advancements in global surgery. Since its establishment in 2015, the LCoGS has been ground-breaking in demonstrating the many opportunities for improvements in global health and global surgery over the next 15 years and beyond. Progress has also been made in surgical safety. For instance, the sustained use of the “WHO Surgical Safety Checklist” led to continued improvements in surgical processes and reductions in 30-day surgical complications in Moldova, a LMIC, almost 2 years after its implementation.[6] Such improvements were seen despite the absence of continued oversight by the research team, demonstrating the important role that local leaders play in the success of quality improvement initiatives, especially in resource-limited settings. Moreover, opportunities to address health inequity and reset the global health agenda have arisen. These include global commitments to achieve Universal Health Coverage and the establishment of the Sustainable Development Goals. Realisation of the various goals to end poverty, ensure health for all, and promote sustainable economic growth, will be more achievable by ensuring delivery of safe, affordable and timely surgical care.[1] However, more improvements can still be made to further the provision of surgery worldwide. Currently, a global fund for surgery does not exist, and only a few foundations are willing to support surgery. Indeed, it took decades of advocacy to demonstrate the huge disease burden of other global health issues such as HIV/AIDs, tuberculosis and malaria, and then to develop funding mechanisms for them. With surgeons and leaders in global health advocating for patients in LMICs, we can hope to push for financial support in the coming years in order to improve the infrastructure and access to safe surgical care. In order to improve training and facilitate sharing of resources, there should also be further collaboration between hospitals in high income countries and LMICs (“twinning programs”). [3] However, donor hospitals, surgeons, and all those involved in efforts to redistribute surgical supplies need to exercise due diligence by ensuring that their partner institutions, including hospitals, clinics and medical schools, commit to reaching the poorest populations. Additionally, it is important to integrate vertical surgical programs into broader efforts to improve public health. In doing so, several important questions need to be raised: how effectively are the partner institutions providing care? Are they meeting broader goals of public health and global health equity?[3,7,8] Finally, professional interest groups starting at the level of medical students and residents can foster interest and educate others about surgery in a global healthcare setting. One such entity is the International Student Surgical Network (InciSioN). This international team of medical students and young doctors, began as a small working group within the International Federation of Medical Student Associations (IFMSA) in 2014. Since its initiation, members of InciSioN have been passionately active in global surgery research, advocacy and education. Conclusion Considering the significant economic and disease burden of lack of access to safe surgical care, surgery is truly a necessity and not a luxury. Put simply, essential surgical care should be made accessible and available to everyone in the public sector. Whilst the challenges are huge, progress in global surgery can be made with patience, determination and 24
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Page 3 and 4: Contents Editor’s Note: The Sky
Page 5 and 6: Rise of Trump/Fall of Health [Comme
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Page 9 and 10: may perceive the risks from vaccina
Page 11 and 12: Climate Change and Vector-Borne Dis
Page 13 and 14: REFUGEE AND ASYLUM SEEKER UPDATE MA
Page 15 and 16: Just two weeks after Dukhan’s let
Page 17 and 18: Redefining Women’s Health: A Nonc
Page 19 and 20: posit in Women’s Health: A New Gl
Page 21 and 22: Healthcare in Conflict Zones [Featu
Page 23 and 24: to bring governments and warring fa
Page 25: Surgery: Luxury or Necessity? [Feat
Page 29 and 30: Beyond the horizon and back again I
Page 31 and 32: soft-drinks in day-to-day practice.
Page 33 and 34: prevention method.[15] At-risk indi
Page 35 and 36: Mental illness following disasters
Page 37 and 38: increase the incidence of disasters
Page 39 and 40: Factors that contribute to the redu
Page 41 and 42: does not allow for the provision of
Page 43 and 44: Medical electives in resource-poor
Page 45 and 46: the tensions which exist between se
Page 47 and 48: IFMSA - 5 letters with one big miss
Page 49 and 50: Health, was involved in presenting
Page 51 and 52: million more people into extreme po
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