Lucky to be here

OUTSIDE THE SURGICAL theatre at Koidu hospital in Sierra Leone’s Kono district, Therisa Mye-Komara explains that until a few years ago surgeons would operate by torchlight in the evenings. Things are better now, says the surgical nurse. There is a generator to provide round-the-clock electricity, an oxygen machine to supply the anaesthetic equipment and an anaesthetist who can use the kit. “It is very rare for us to lose a patient on the table,” she says. But Ms Mye-Komara readily concedes that “we do not have the know-how” for many of the operations needed.

Nine in ten people living in developing countries do not have access to “safe and affordable” surgical care, according to a report in 2015 by the Lancet (see map). About 60% of operations round the globe are concentrated in countries with only 15% of the world’s population. In rich countries a rough rule of thumb suggests there will be about 5,000 operations per 100,000 people every year. But according to the African Surgical Outcomes Study, a survey of 25 African countries, the median rate on that continent is just 212 per 100,000.

Surgery may seem something of a luxury if funds are tight, but the consequences of not having access to it are profound. In 2010, 17m lives were lost from conditions needing surgical care, dwarfing those from HIV/AIDS (1.5m), TB (1.2m) and malaria (also 1.2m). Roughly one-third of the global disease burden measured by DALYs is from conditions requiring surgery.

Lack of emergency obstetric care is a case in point. The WHO estimates that 5% of births may require a caesarean section. But in a survey of east African countries back in 2005, less than 1% of women there had access to such treatment. Globally, 1bn women would not get the urgent care they would need in the event of complications with a pregnancy.

Surgery is also more likely than other forms of care to have severe financial consequences, says Anna Dare of the University of Toronto. An operation is often a matter of life or death, so there may be no time to put funds aside for it. Some 57% of operations in developing countries are for emergencies, compared with 25% in rich ones. A recent study in rural Bangladesh found that 10-22% of patients with acute surgical conditions, such as a post-delivery hysterectomy, ended up in poverty. For those with conditions that did not require surgery the figure was 3.4%.

Jim Yong Kim, now president of the World Bank, and Paul Farmer, the founder of Partners in Health, the American health charity, noted in 2008 that surgery is the “neglected stepchild” of global health. It remains neglected, for several reasons. One is an image problem, notes Justine Davies, one of the authors of the Lancet report: surgery is seen as an expensive luxury. Another is that because it is used to treat many different conditions, it holds less appeal for aid donors, who like to focus on specific diseases such as HIV/AIDS or malaria.

But as the DCP3 report by the University of Washington shows, surgery is an essential part of any universal-health-care scheme. The report identifies 44 essential procedures that, if widely available, could avert 1.5m deaths a year at a global cost of $3bn. Most of them can be carried out at smaller district hospitals. These “rank among the most cost-effective of all health interventions”. A caesarean section costs between $15 and $380 for every year of disability (DALY) averted, cataract surgery $50 and hernia repair between $10 and $100. Anti-retroviral treatment for HIV/AIDS costs $900 per DALY. Such metrics rely on debatable assumptions, but they do suggest that basic procedures can have large benefits at low cost.

More for less

The question is how poor countries can expand their surgical capacity. The 25 countries in the African Surgical Outcomes Study had an average of 0.7 surgeons, obstetricians and anaesthetists per 100,000 people, compared with a typical figure of more than 40 in the rich world. Over half the district hospitals in one study of eight African countries had no anaesthesia machine. Often the kit is donated, and few locals know how to fix it. One survey suggests that 40% of donated surgical equipment in poor countries is out of service.

Training more surgeons is clearly vital, but there are other ways to make surgery more accessible, such as getting it done by more junior staff. In a review of studies conducted in countries such as Malawi, Mozambique and Tanzania, clinical officers with about three years of training performed caesarean sections as safely as doctors did. Technology can help, too, such as the cheap pulse oximeters to measure blood-oxygen saturation developed by Lifebox, a charity.

Even more important, surgery needs to be a core part of the broader health system, or else referrals will be made too late, and primary-care clinics will not be able to keep an eye on patients after surgery. The African Surgical Outcomes Study found that the death rate following surgery across the continent was twice the global average. What happens after a patient leaves the operating table is as important as the surgery itself.