The first time I read the Lancet commission on global surgery report Global Surgery 2030 I was astounded by the numbers: 143 million additional surgical procedures are needed in low- and middle-income countries (LMICs) yearly, only 6% of surgeries occur in the poorest countries in the world where 33% of the global population lives, and, of course, the fact that 5 billion people lack access to safe and affordable surgical care. This last statistic struck me the most. Considering the world’s population in 2015 was 7.4 billion, this implies that only 32.4% of individuals worldwide have access to cost-effective, secure surgical services. 32.4%! This realization led me to question the broader implications. For instance, what fraction of the world have access to clinical trials? Are the studies we use to guide clinical practice only based off 32.4%? When providing a patient with a prognosis for their surgical disease, do I ever stop to reflect on the fact that I’m quoting them the prognosis based on them being in the 32.4%? Suppose we were to unearth the cure for colon, pancreas, or another surgically treatable cancer, do we realize that in our present global context our capacity to cure is effectively capped at 32.4%? This was a poignant wake-up call, a stark reminder that the research and innovation we do is currently encapsulated in a bubble. Regardless of how efficacious our therapies are, we literally cannot cure surgical diseases in this current global context.
What is the course of action? While the answer is undoubtedly multifactorial, one key component is data. It is hard to create calculated solutions to problems without measurements. Data collection and analysis is a crucial tool in the improvement of surgical outcomes. At a baseline it gives us disease prevalence but can be leveraged for quality improvement (QI), risk stratification, clinical trials, and geospatial analysis of disease. Many high-income countries have national surgical QI programs that utilize risk-adjusted models to guide quality initiatives and enhance perioperative outcomes. These programs have yielded strikingly positive results. For instance, in the early 2000s the US National Surgical Quality Improvement Program (NSQIP) resulted in a drop in postoperative morbidity and mortality rates by 47% and 43% respectively within 15 years of implementation.
Such large-scale programs are absent in LMICs. The challenges to implementing national surgical registries in these countries are many and daunting, and include technical, organizational, and behavioral barriers. Despite these challenges, it is essential that we find ways to overcome these obstacles to improve surgical outcomes in these settings. I currently work with a team involving a collaboration with Hawassa University (HU) in Ethiopia in which we have initiated a prospective perioperative general surgery registry. This is a novel endeavor in this resource constrained environment. I was recently blessed to win the Association for Academic Surgery Global Surgery Research Fellowship award, which will fund the risk-adjustment of this registry as well as preparation for eventual expansion. This prospective perioperative surgical registry, once risk-adjusted, will facilitate internal QI projects, continuous QI maintenance analysis, and eventual expansion of similar surgical registries to other sites (perhaps a future global or LMIC NSQIP… but I digress). This project’s success is wholly due to the hard-working team members on the ground in Hawassa who are constantly working to build this registry. It is a true reflection of global surgery work: teamwork, collaboration, and hearts focused on improving care for our patients.
I will conclude by making a call to every surgeon, researcher, or interested person. Continue working to improve care for people. Continue to recognize the innate dignity of every single person and know that they deserve people fighting for them. Continue to make new discoveries, develop new technologies, and strive to cure surgical disease. However, take time to reflect on how your work can expand beyond the 32.4%. Remember that those in need reside not only half-way across the world but also within our own communities. Whether it be through improving data collection in under-resourced areas, developing technology that is adapted to difficult environments, optimizing systems, advocating for policy changes or other research, there is a role for everyone in the global surgery sphere. As surgeons, our expertise lies not just in our surgical prowess but also in our innovative problem-solving. Ensuring equitable access to the fruits of our labor is indeed a multifaceted issue, but it is one our skill set is primed to solve.
Taylor Jaraczewski, MD, MS
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- Popping the 32.4% Bubble - November 3, 2023