Although global health has come a long way over the past 25 years, access to surgical care remains very uneven across the world. Five billion people lack access to basic surgical care; this translates into unnecessary death and disability. More than one-third of all global deaths are from conditions requiring surgical care—more than the number of deaths from HIV/AIDs, tuberculosis and malaria combined. In addition, one-quarter of the world’s disability has been attributed to surgically treatable conditions.
In January 2014, an international team of 25 surgeons and public health experts launched The Lancet Commission on Global Surgery to address the widespread need for surgical care around the world. After 14 months of global consultation and four international meetings, the commission published a 32,000- word report today in The Lancet that provides a strategy for governments, policy makers, non-profits, funding agencies, academic institutions, professional associations, health care providers and local communities to engage in concrete action in low- and middle-income countries.
On May 6, the commission hosts its North American launch in Boston to present its key findings and priority action items. John G. Meara, MD, DMD, MBA, Plastic Surgeon-in Chief at Boston Children’s Hospital and the Kletjian Professor of Global Surgery at Harvard Medical School, is one of three chairs of the commission. We sat down with Meara to learn more about the commission’s work, which he describes as one of the “most impactful things he has done in his career to date.”
What’s the mission of The Lancet Commission on Global Surgery?
Our vision is universal access to safe, affordable, surgical and anesthesia care when needed. We did some mathematical modeling and found that there are actually about 5 billion out of 7 billion people in the world who don’t have access to safe, affordable, surgical and anesthesia care when they need it. For some people, that means it’s a 12-hour donkey ride to reach an operating theater. So if you need care now, you can’t get there in time. Other people can’t afford it. Due to poverty in a number of these countries, getting a femur fracture fixed might be three times the annual GDP per capita for that country. And some people can show up at the hospital and pay, but there’s no electricity, or there’s no anesthesiologist, or there’s no surgeon. If you put access, timeliness, affordability and safety all together, a huge percentage of the globe lacks access to surgical care, which is frightening.
The Lancet editor Richard Horton set some goals for us: Analyze the situation in global surgery, and then come up with recommendations for improvement and metrics to track what is going on in the world. At the end of the day, we ended up engaging 111 countries and upwards of 1,000 people through various meetings, direct interviews and social media.
Global health efforts have tended to focus on specific diseases or populations, not procedures. Why hasn’t global surgery attracted more attention?
Historically, people thought that surgery was too expensive, so they looked at other things that didn’t seem as expensive or complex—like immunization, where you have a needle, and you immunize and then you’re done, versus surgery, where you need nurses, an operating room, electricity, instruments. People said, “If we only have $1 million, what’s the most effective way to use $1 million?” Well, maybe it’s buying immunizations.
But what we found is that you need a fully functional system to really help a country. A proper surgical system brings with it all the things you need to have a good, overall health care system: operating rooms, sterile equipment, sterilizing procedure, electricity. If you’re willing to make the investment in surgical care, it raises the capacity of the whole system. As Partners in Health (PIH) co-founder Paul Farmer once said, “It’s silly to spend thousands of dollars on antiviral medications only to have that patient die the next week from a perforated appendix.”
The report estimates that 143 million additional surgical procedures are needed in low- and middle-income countries each year. How much investment will that require?
Even if you take some of our conservative targets, you basically would have to double the number of surgeons in those countries over the next 15 years. There will be some investment required. It’s going to cost $350 billion to bring low- and middle-income countries up to the safety and quality levels we’re talking about. However, the impact on their economies could be $12.3 trillion, so the return could be quite good. It’s just that $350 billion is a lot of money. We show in the report that surgery is cost-effective because of its impact on the country’s economy. Even though fixing a femur fracture is expensive, you’re putting someone back in the workforce for the next, say, 40 years of that person’s life, so the economic impact of fixing that femur can be huge. We show that not addressing surgical care between now and 2030 could take 2 percent of a country’s projected annual GDP growth right off the top. That’s going to have a chilling effect on their growth and development.
Doubling the number of surgeons over the next 15 years, $350 billion…. How do you go about addressing such large-scale need?
There’s no single silver bullet. The Lancet Commission provided a nice strategic construct, and now what we need to do is help low- and middle-income countries look at each aspect of their surgical care and come up with a scorecard. We’ve developed a template called a “national surgical plan” that ministers of health can look at and check through to see what they need. Every country will have to be willing to roll up its sleeves and look at these recommendations and decide what fits for them. Every country will have slightly different issues and slightly different solutions.
How did you first get involved in global surgery?
My specialty—plastic surgery—has a long history of doing global health work, like cleft lip and palate surgeries. I got involved initially in those types of trips, and when I came back to Boston after being away for a while, Paul Farmer asked if I would expand surgical care in Partners in Health. In 2006, I started to work with them, and in 2008 we started the Paul Farmer Global Surgery Fellowship program together, which has grown exponentially from one fellow in our first year to 21 fellows for this coming year. The program is not so much about going somewhere, providing a week of care and leaving. It’s about going somewhere and helping them to expand their educational programs, expand their own care-delivery infrastructure,and develop a research infrastructure. The whole global health community has moved towards feeling like building capacity has to be part of what we do over the long term.
Boston Children’s was the only children’s hospital involved in The Lancet Commission on Global Surgery. How does pediatrics tie into the global surgery conversation?
Pediatrics is an incredibly important part of global surgery. Pediatric care is hugely dependent on surgery—for appendicitis, trauma, congenital anomalies, cancer, etc. Surgery is really important to prevent mortality in children under age 5, for example. The whole maternal child health movement is heavily predicated on good access to surgery for safe caesarian delivery.
Children’s hospitals normally aren’t quite as visible in global health, so it’s great that Boston Children’s was able to be one of the main participants here. That’s pretty unusual.
After the May 6 event, what’s next up for the commission?
We didn’t want to produce an academic document that sits on a shelf in the library. This is meant to be a policy document that helps ministers of health scale up surgery, a document that addresses how USAID, the World Bank, the World Health Organization, funding agencies and academic medical centers should get involved. We’re going to have launches in Brazil, Melbourne, India, Africa, Haiti, Asia and other parts of the world to present our findings and discuss priority action items. Ultimately, our hope is that The Lancet Commission indicators will be collected by all ministries of health and published on the World Bank’s World Development Indicators website as a means of tracking improvement towards our goal of universal access to safe, affordable, surgical and anesthesia care when needed.