Global surgery: a cause worth advocating for

With global and public health in a newfound limelight, Joe Incorvia ’15 advocates for better access to surgeries in low- and middle-income countries in the latest Point of View.

A biochemistry graduate, Joe Incorvia ’15 is a quality improvement consultant in the plastic surgery department at Boston Children’s Hospital. He was formerly a researcher at Harvard Medical School’s Program in Global Surgery and Social Change, which advocates for universal access to safe, affordable surgical, obstetric and anesthesia care when needed.

The first time someone died in front of me was in a national hospital in Uganda in the summer of 2016. A gurney rushed down the dimly lit hallway. Nurses yelled in the local language. The procession entered the large ward, illuminated in some natural light. A man in his early 20s laid there, legs twisted, arms limply hanging off the sides. What I noticed the most were a massive head wound and blank stare. The gurney came to a stop about a meter from me and the patient started to convulse. The nurses began providing care. As he was writhing, one of the nurses turned to me. I will never forget her plea to help and “just hold” as she pointed to his legs. I was just there to collect data for my master’s thesis on access to surgical care in Uganda; I was not prepared to assist in a medical emergency. “Please!” she yelled. The next moments were a blur. I’m not sure how many minutes passed. I don’t remember what they did to help him. I just remember the unmistakable sight of life leaving his eyes. I didn’t collect much data that day.

I don’t tell this story much. To me, it’s an internal reminder of the importance of global surgery work. Dr. Paul Farmer, founder of Partners in Health, and Dr. Jim Kim, former president of the World Bank, famously called global surgery the neglected stepchild of global health. When people think global health they think of infectious diseases like HIV, malaria, tuberculosis and, recently, the novel coronavirus. However, global health encompasses finding solutions to a variety of ailments like cancer and diabetes to projects focusing on water and sanitation in the world’s most vulnerable populations.

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Global surgery focuses on improving the surgical capacity of health systems all over the world. More than 5 billion people do not have access to safe, affordable and timely surgical and anesthesia care. Access is the worst in low- and middle-income countries, where 6 percent of all surgical procedures occur. In fact, 143 million additional surgical procedures are needed in these countries yearly to save lives and prevent disability. Further, 33 million people face catastrophic health expenditure for surgical procedures each year with an additional 48 million facing similar economic distress simply trying to access care.

This is related to the surgical capacity in the poorest countries on earth. In Uganda for example, as of 2016, there were six neurosurgeons for a country of 33 million people (1:5.5 million). In comparison, the U.S. has 5,000-plus neurosurgeons for 330 million people (1:65,580). All surgical specialties have similar shortages in human resources, along with shortages in nurses, anesthesiologists and OB-GYNs. Disease treatable by surgery is a ranking killer of the world’s poorest populations. Yet, major funders tend to disregard the importance of investment in surgical care on a global scale.

That’s what global surgery is about — making change to give a fighting chance to those who are the most marginalized and vulnerable in the poorest countries.

Neurosurgery may seem a bit removed. It is not something that affects us on a regular basis. However, good obstetric care and safe access to cesarean section is something that we all hope to have. More than 500,000 women die each year in childbirth. These deaths are largely attributable to an absence of surgical services to stop postpartum hemorrhage. This global problem is also one we face in the U.S. with only 23.4 percent of the population having 30-minute access to adequate obstetric care if they are at high risk for complication. Add to that the number of motor vehicle accidents, fractures and congenital anomalies that also require surgical services and we’re only scraping the surface of the myriad of conditions that require surgical interventions.

What can we do? While the picture painted seems bleak, there is much hope. Investment in surgery is feasible and cost-effective. There are many efforts to build surgical capacity across the world and domestically. Governments face major decisions on how to invest their resources every day, yet we continue to advocate for strengthening of surgical systems because surgery, as Dr. Kim puts it, is an “indivisible, indispensable part of health care.”

Would a better capacity for neurosurgery have been able to save the young man in Uganda? That’s a complicated question to answer that depends on many facets of the health system and hospital. But, would it have given him a better chance at survival? There is no doubt. That’s what global surgery is about — making change to give a fighting chance to those who are the most marginalized and vulnerable in the poorest countries. For me, that is a cause worth advocating for.