Safe surgery unavailable to 5 billion people, study finds

Five billion people worldwide don't have access to safe and affordable surgery, a critical need for health and welfare that has been overlooked by the global community, says a team of 25 medical experts from around the world.

The report, which appeared Sunday in the online edition of The Lancet, contains an estimate that nearly a third of deaths in 2010 — 16.9 million — were from conditions treatable with surgery, which the authors say far surpasses deaths from communicable diseases like HIV/AIDS (1.46 million), tuberculosis (1.2 million) and malaria (1.17 million) combined.

"Too many people are dying from common, treatable surgical conditions, such as appendicitis, obstructed labour and fractures," Lars Hagander, one of the report's lead authors from Lund University, Sweden, says in a release.

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The estimates of access to surgery are based on information provided by physicians and anesthesia providers from 110 countries. Four primary factors were considered: whether surgical facilities exist; whether those facilities can be reached in a timely manner by patients; if procedures can be done safely; and if procedures are affordable. 

The researchers found at least 143 million needed surgical procedures — many for conditions relatively easy to treat — are never done, resulting in unnecessary deaths and economic costs. In some cases, those affected are pushed to the margins of society. 

In other instances, even when treatment is provided, it drives patients into cycles of extreme poverty because of high costs, the study found. 

New development priorities

The problem is particularly acute in low- and middle-income countries, where an estimated nine out of 10 people do not have access to surgery. In many cases, a lack of trained medical professionals is at the heart of the problem. In the southeast African country of Burundi, for example, there are only 15 surgeons for a population of 10 million, while in Rwanda there are 50 surgeons serving 11 million people. 

About 313 million surgical procedures are carried out worldwide each year, but only six per cent occur in the poorest countries, where over a third of the world's population lives, the study's authors say. 

"The need for equitable and affordable access to surgical services is projected to increase in the coming decades, as many of the worst-affected countries face rising rates of cancer, cardiovascular disease and road accidents," says co-author Andy Leather of the King's College Centre for Global Health. 

Access to surgery has been largely overlooked on the development agenda, which tends to focus on infectious diseases, Leather says. "We're hoping this will be a wake-up call so it can be prioritized at a global and national level."

Treatable conditions

Dr. Dan Deckelbaum, a surgeon and co-director of the Centre for Global Surgery at McGill University Health Centre who regularly travels to East Africa to train health-care workers, welcomes the attention on surgery needs worldwide.

"The important thing is that these are all preventable deaths with an appropriate infrastructure," he says. 

Deckelbaum, who was not involved in the study, recalls a case involving a 12-year-old boy in the Samburu region of northern Kenya who was shot in the jaw. He had to walk for six hours and then hitch a ride for another four-hour trip by road to reach a health-care facility.

"These are the challenges we see in these resource-limited settings," he says. "The injuries, even though they are survivable, the patient does not arrive in time to give them a chance at appropriate treatment."

Fortunately, the boy in Deckelbaum's anecdote managed to survive after being airlifted to a hospital in Nairobi for surgery. 

Basic surgical services

The study suggests that in countries where access to surgery is weakest, achievable goals could be reached by 2030 with an investment of $420 billion US. The researchers set that bar at a minimum of 20 surgeons per 100,000 people in any country.

Currently in the U.K. there are about 35 surgeons per 100,000, for example, while in sub-Saharan Somalia, the rate is 0.1 per 100,000.

A crucial aspect of improving access is to train more local medical professionals to carry out relatively simple but life-saving procedures in vastly under-served regions. Leather says that about 80 per cent of surgical procedures can be completed in a safe and effective way by teams with rudimentary treatment and facilities.

To achieve the goals, provisions such as reliable electricity, running water, oxygen and blood supply need to be in place, the study says.