The global burden of conditions requiring surgical care, such as injuries, congenital anomalies, cancer, and complications from childbirth, is large and continues to grow. Recent estimates indicate that a limited number of surgical conditions represent 18 percent of the global burden of disease.1 Nonetheless, marked disparities in access to surgical and anesthesia care persist worldwide. Billions of people have no access to basic surgical services, resulting in heavy human and economic toll.2-5 Despite this growing need, surgery has typically been a low priority on the global public health agenda. It has been viewed as too expensive, too complicated, and less integral to health than other areas of medicine.
Recent changes in the public health landscape, however, have led to a growing appreciation of the importance of surgery in realizing widespread improvements in health on a global scale. An evolving epidemiologic transition in which noncommunicable diseases (NCDs) and injuries are emerging as new leading causes of global death and disability, and mounting research documenting the feasibility and cost-effectiveness of surgical care delivery, have opened the eyes of many people.6,7 In addition, evidence that surgery is a necessary treatment modality across all disease categories and a shift in global health goals toward prioritization of equity and provision of universal health coverage (UHC) are causing more people to realize “that surgery is an indivisible, indispensable part of health care.”8-10
In recognition of the potential benefits of increasing surgery’s role in global health, The Lancet Commission on Global Surgery (LCoGS) was launched in January 2014.11 The initial LCoGS aims are to help facilitate recognition of the essential role of surgery not only to a properly functioning health care system but to the health of populations across the life course, to define the current state of surgical care delivery around the world, and to develop recommendations to improve the status of global surgical care.11 This article—an update to an article published in the February 2014 issue of the Bulletin—provides a current overview of the commission and its accomplishments over the last year.12
The Lancet commissions
The Lancet’s dedication to global health emerged in 2003 when it published a series of articles on child survival.13 Since then, The Lancet has published additional series and has formed multiple commissions focused on various global health topics, including investing in health, medical education, cancer care, and climate change. The purpose of these commissions is to guide and ignite policy change and to generate widespread and longstanding improvement for frequently neglected global health issues. The commissions’ work typically begins with the publication of a report in The Lancet, written by a multidisciplinary group of experts from around the world. The commissions’ efforts are then sustained through advocacy efforts and the publication of subsequent reports.
Global surgery is a field that aims to improve health and health equity for all people who are affected by surgical conditions or have a need for surgical care, with a particular focus on underserved populations in countries of all income levels, as well as populations in crisis, such as those experiencing conflict, displacement, and disaster.14 In early 2013 a small group of surgeons dedicated to global surgery initiated discussions with The Lancet regarding the critical need for improvements in global surgical care delivery. The Lancet recognized this need, and plans to form a commission on global surgery began.
The strategy behind this initiative was to bring together a group of experts in health care financing, economics, and policy; look at the current picture of surgical care in low- and middle-income countries; and formulate recommendations for improving the delivery of surgical services around the world.
LCoGS is composed of three chairs, 22 commissioners, and numerous advisors and research assistants.15 The chairs are John G. Meara, MD, DMD, MBA, FACS, Boston Children’s Hospital and Harvard Medical School, MA, (co-author of this article); Andy Leather, MB, BS, FRCS, King’s College London, U.K.; and Lars Hagander, MD, PhD, MPH, Lund University, Sweden. The commissioners, from 14 countries, have broad experience spanning surgical, anesthetic, obstetric, and oncologic care delivery through private, public, and non-governmental organizations (NGOs); health care policy, financing, economics, and research; and health and governmental systems.
The commissioners met three times in 2014 to discuss how to improve the state of global surgery and to develop the commission report. The first meeting took place in Boston in January 2014, with more than 100 participants from 18 countries.16 The purpose of this meeting was to introduce the commission process, determine areas of focus for subsequent work, and initiate discussions on key issues.
The second meeting took place in June in Freetown, Sierra Leone, with participants from 28 countries.17 Commissioners and participants discussed the results of deliberations and research conducted in the preceding five months and issued preliminary decisions on the key messages and recommendations for the commission report. The final commissioner meeting was in November in Dubai, U.A.E.18 Peer-review comments on the report were discussed and responses determined.
In addition to the three primary commissioner meetings, numerous regional meetings took place in 2014.19 The purpose of these meetings was to generate discussions with additional participants from around the world to guide the commission’s process and report content. Regional meetings convened in Cartagena, Colombia; São Paulo, Brazil; Chhattisgarh, India; and Singapore. (See Figure 1 for a chart of the commission’s work and timeline.)
Figure 1. Commission Process
The initial commission output will be a 32,000-word report published in The Lancet at the end of April (the executive summary of which will be published in the June issue of the Bulletin). This report will coincide with the first LCoGS launch in London, April 27 and 28, during which time the main findings and recommendations of the commission will be discussed in a public and interactive format. The report will be accompanied by a group of supporting primary research papers, in addition to a collection of global surgery teaching cases illustrating successful and unsuccessful methods of surgical care delivery.20 Publication of this initial body of work will mark the start of a long-term advocacy effort by the commission and supporting groups to improve global surgical care delivery.
Much of LCoGS’s success hinges on the global community’s widespread input into and involvement in its efforts. Therefore, in addition to the meetings described previously, LCoGS has worked extensively to engage as many stakeholders as possible, including various ministries of health; global health and development organizations, including the World Bank, the World Health Organization (WHO), and USAID; funders; surgical colleges; and patients and providers, regarding the status of global surgery and how to improve it. Multiple quantitative and qualitative surveys were conducted online, in-person, and via Skype or telephone to further elicit opinions on areas of global surgery importance. In addition, numerous research groups and individuals were asked to develop stand-alone global surgery publications and teaching cases for publication alongside the LCoGS report.
These engagement efforts yielded collaborations from more than 110 countries in 2014 (see Figure 2).
Figure 2. Global community engagement with LCoGS
Building on prior efforts
LCoGS is not the first organized effort to advocate for surgery as a vital component of the global public health agenda. On the contrary—its work would not be possible without the efforts of many groups and individuals. For example, NGOs and humanitarian groups, such as Médecins Sans Frontières (MSF), which began its first surgical work in the Chad-Libya war, have demonstrated the feasibility of and need for provision of surgical services in remote and low-resource settings through direct care delivery.21 Global health leaders such as Halfdan T. Mahler, MD, former director-general of the WHO, have argued for surgery’s role in facilitating a comprehensive picture of health care, stating that “surgery clearly has an important role to play in primary health care and in the services supporting it.”22 The WHO has initiated or supported several efforts to strengthen global surgical care delivery, such as those of the Global Initiative for Emergency and Essential Surgical Care. The Bellagio Essential Surgery Group was formed in 2007 to advocate for improved access to surgical care within sub-Saharan Africa, generating some of the most widely-referenced global surgery reports to date.23,24 Many additional groups, such as The Alliance for Surgery and Anesthesia Presence, the American College of Surgeons (ACS) Operation Giving Back program (OGB), and both the second and third editions of Disease Control Priorities, have worked tirelessly on a number of global surgery efforts in the areas of education, research, advocacy and policy.25,26 These are just a few of many examples of past and current global surgery work. LCoGS hopes to augment these efforts in order to facilitate the development, implementation, and evaluation of surgical policy and to promote the delivery of surgical services worldwide.
The ACS and global surgery
Alongside the groups discussed previously, the ACS has long demonstrated a commitment to leadership, education, and participation in global surgery. In the midst of a growing interest among surgeons and residents in global surgery work, the ACS has taken the initiative to provide a gateway for surgeons in different stages of their careers to get involved in global surgery efforts around the world.27 Programs such as OGB provide U.S. surgeons with the opportunity to connect with their international counterparts to coordinate volunteer efforts and address the surgical needs of underserved populations. The ACS/Pfizer Surgical Volunteerism and Humanitarian Awards are given annually to recognize ACS members who have demonstrated dedication to giving back to underserved populations and to society.
In addition, the ACS offers a number of scholarships for international surgeons, providing opportunities to support clinical, teaching, education, and research activities. A significant contribution of the ACS to medical education around the world has been the development of the Advanced Trauma Life Support® (ATLS®) course. Since its introduction in 1978, ATLS has trained more than 1 million health care professionals in emergency and trauma care. The ACS is a strong advocate for global surgery advancement and stands at the front line of bringing surgical care to people most in need.
A political environment in transition
The current political environment is poised for change. Attention is transitioning from the United Nations’ Millennium Development Goals—a set of eight goals to advance global health and development with target end dates of 2015—to the new and somewhat broader post-2015 Sustainable Development Goals (SDGs), Universal Health Coverage (UHC), and challenging commitments to equity and the end poverty.28,29 The only health-related SDG is to “ensure healthy lives and promote well-being for all at all ages.”29 The World Bank and WHO have targeted 80 percent coverage of essential health care services by 2030 as a measure of UHC.9 The World Bank also aims to end extreme poverty by 2030.30 None of these goals is attainable without including surgery as an integral component of a functional health care system. Focus on these goals, therefore, creates an unprecedented occasion to recognize the necessity of universal access to safe, affordable, surgical and anesthesia care in realizing widespread improvements in global health.
As noted previously, the commission report and first round of supporting research and teaching cases will be published in April in conjunction with the first launch in London, April 27 and 28.31 This will be followed by the first North American launch in Boston, May 6 and 7.32 These events will provide opportunities for discussion of LCoGS’ work and findings, offer attendees a chance to deliberate ways to improve global surgical care delivery, and strategize solutions for how surgical organizations such as the ACS can work together, as World Bank president Jim Yong Kim, MD, PhD, stated in his address at the inaugural commission meeting, “to build a shared vision and strategy for global equity in essential surgical care.”10
- Bickler SW, Weiser T, Kassenbaum N, et al. Chapter 2: Global burden of surgical conditions. Disease Control Priorities, 3rd Edition: Economic Evaluation for Health. New York, NY: Oxford University Press. [In press March 2015.]
- Alkire B, Hughes CD, Nash K, Vincent JR, Meara JG. Potential economic benefit of cleft lip and palate repair in sub-Saharan Africa. World J Surg. 2011;35(6):1194-1201.
- Funk LM, Weiser TG, Berry WR, et al. Global operating theatre distribution and pulse oximetry supply: An estimation from reported data. Lancet. 2010;376(9746):1055-1061.
- Kotagal M, Agarwal-Harding KJ, Mock C, Quansah R, Arreola-Risa C, Meara JG. Health and economic benefits of improved injury prevention and trauma care worldwide. PLoS One. 2014;9(3):e91862.
- Mock CN, Donkor P, Gawande A, Jamison DT, Kruk ME, Debas HT. Essential surgery: Key messages from Disease Control Priorities, 3rd Edition. Lancet. February 2015. [Epub ahead of print.]
- Verguet S, Norheim OF, Olson ZD, Yamey G, Jamison DT. Annual rates of decline in child, maternal, HIV, and tuberculosis mortality across 109 countries of low and middle income from 1990 to 2013: An assessment of the feasibility of post-2015 goals. Lancet Glob Health. 2014;2(12):e698-709.
- Chao TE, Sharma K, Mandigo M, et al. Cost-effectiveness of surgery and its policy implications for global health: A systematic review and analysis. Lancet Glob Health. 2014;2(6):e334-e345.
- Rose J, Chang DC, Weiser TG, Kassebaum NJ, Bickler SW. The role of surgery in global health: Analysis of United States inpatient procedure frequency by condition using the Global Burden of Disease 2010 framework. PLoS One. 2014;9(2):e89693.
- Monitoring progress towards universal health coverage at country and global levels: Framework, measures, targets. May 2014. World Health Organization and International Bank for Reconstruction and Development/The World Bank. Available at: http://apps.who.int/iris/bitstream/10665/112824/1/WHO_HIS_HIA_14.1_eng.pdf. Accessed February 12, 2015.
- Kim JY. Opening address at the inaugural meeting of The Lancet Commission on Global Surgery. First Meeting of The Lancet Commission on Global Surgery. January 17, 2014; Boston, MA, USA. Available at www.globalsurgery.info/video/. Accessed February 1, 2015.
- Meara JG, Hagander L, Leather AJ. Surgery and global health: A Lancet Commission. Lancet. 2014;383(9911):12-13.
- American College of Surgeons. Lancet Commission on Global Surgery convenes. Bull Am Coll Surg. 2014;99(2):52.
- The Lancet: Child survival series. June 23, 2003. Available at: www.thelancet.com/series/child-survival. Accessed February 23, 2015.
- Dare AJ, Grimes CE, Gillies R, et al. Global surgery: Defining an emerging global health field. Lancet. 2014;384(9961):2245-2247.
- The Lancet Commission on Global Surgery: Commissioners. 2015. Available at: www.globalsurgery.info/commissioners/. Accessed February 12, 2015.
- The Lancet Commission on Global Surgery: January meeting. 2015. Available at: www.globalsurgery.info/meetings/january-meeting/. Accessed February 12, 2015.
- The Lancet Commission on Global Surgery: June meeting. 2015. Available at: www.globalsurgery.info/meetings/june-meeting/. Accessed February 12, 2015.
- The Lancet Commission on Global Surgery: November meeting. 2015. Available at: www.globalsurgery.info/meetings/november-meeting/. Accessed February 12, 2015.
- The Lancet Commission on Global Surgery: Regional meetings. Available at: www.globalsurgery.info/regional-meetings/. Accessed February 12, 2015.
- The Lancet Commission on Global Surgery: Teaching cases. Available at: www.globalsurgery.info/teaching-cases/. Accessed February 12, 2015.
- Chu K, Rosseel P, Trelles M, Gielis P. Surgeons without borders: A brief history of surgery at Médecins Sans Frontières. World J Surg. 2010; 34(3):411-414.
- Mahler H. Surgery and health for all: Address to the XXII Biennial World Congress of the International College of Surgeons. June 29, 1980; Mexico City, Mexico. Available at: www.who.int/surgery/strategies/Mahler1980speech.pdf?ua=1. Accessed February 1, 2015.
- Luboga S, Macfarlane SB, von Schreeb J, et al. Increasing access to surgical services in sub-Saharan Africa: Priorities for national and international agencies recommended by the Bellagio Essential Surgery Group. PLoS Medicine. 2009;6(12):e1000200.
- Increasing access to surgical services in resource-constrained settings in sub-Saharan Africa. Bellagio Essential Surgery Group Meeting final report. 2008. Available at: www.essentialsurgery.org/bellagio/docs/2008_kampala_essential_surgery_report.pdf. Accessed February 1, 2015.
- Jamison DT, Breman JG, Measham AR, et al. Disease Control Priorities in Developing Countries, Second Edition. Washington, DC: Oxford University Press and The World Bank; 2006.
- University of Washington. Department of Global Health. Disease control priorities (DCP3). Available at: www.dcp-3.org. Accessed January 23, 2015.
- Powell AC, Casey K, Liewehr DJ, Hayanga A, James TA, Cherr GS. Results of a national survey of surgical resident interest in international experience, electives, and volunteerism. J Am Coll Surg. 2009;208(2):304-312.
- United Nations. News on millennium goals. Available at: www.un.org/millenniumgoals/. Accessed February 23, 2015.
- United Nations. Open working group proposal for sustainable development goals. Available at: https://sustainabledevelopment.un.org/focussdgs.html. Accessed February 23, 2015.
- The World Bank. The World Bank Annual Report 2013. Available at: http://siteresources.worldbank.org/EXTANNREP2013/Resources/9304887-1377201212378/9305896-1377544753431/1_AnnualReport2013_EN.pdf. Accessed February 24, 2015.
- The Royal Society of Medicine. Lancet global surgery commission launch. Available at: www.rsm.ac.uk/events/events-listing/2014-2015/groups/global-health/ghf25-lancet-global-surgery-commission-launch.aspx. Accessed February 12, 2015.
- The Lancet Commission on Global Surgery. Global surgery 2030: Building a movement for sustainable, resilient health systems. Available at: www.globalsurgery.info/global-surgery-2030/. Accessed February 1, 2015.