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From the American Head and Neck Society
December 2016

The Right to Look Human—Head and Neck Surgery in Low- and Middle-Income CountriesThe Chris O’Brien Memorial Lecture

Author Affiliations
  • 1Program in Global Surgery and Social Change, Harvard Medical School, Boston, Massachusetts
  • 2Office of Global Surgery and Health, Massachusetts Eye and Ear Infirmary, Boston
JAMA Otolaryngol Head Neck Surg. 2016;142(12):1143-1144. doi:10.1001/jamaoto.2016.3086

When Sambany, a farmer in his 60s from rural Madagascar, arrived for surgery, he had spent 30 years with a 16-lb tumor on the left side of his face (Figure). In those decades, he had traveled to 10 hospitals, only 3 of which actually had surgeons; none agreed to take his case. Because his mass was removed by volunteer surgeons with Mercy Ships, the surgery itself was free, but transportation to the hospital required the sale of a plot of land, 4 days carried on someone’s back to get to the nearest road, and a 2-day trip by road halfway across the country. Sambany’s head and neck tumor had robbed him of his right to look human. Restoring this right cost him a decade of his life and the loss of his livelihood and required him to travel farther than anyone should for medical care.

Sambany, a Rural Malagasy Farmer in His 60s
Sambany, a Rural Malagasy Farmer in His 60s

Reprinted with permission from Mercy Ships/credit: Ruben Plomp.

As head and neck surgeons, we have spent our careers training for and treating tumors that, like Sambany’s, deny our patients their right to look human. Getting involved in global health has often meant simply extending this clinical care to low- and middle-income countries (LMICs) in which we may serve. This is insufficient. Sambany’s condition was not just a medical issue; his tumor was a symptom of underlying systemic issues that we, as clinicians, are duty bound to diagnose and treat.

The majority of cancer diagnoses in the world occur in LMICs; because of the stigma of cancer, the financial burdens of seeking care, and the lack of available treatment, tumors present late and carry a high case-fatality rate.1 Although multimodality therapy is decades away in many countries, this should not consign patients like Sambany to the denial of treatment: the United States achieved significant reductions in cancer mortality through surgery alone, even before the introduction of adjuvant therapy.1

Cancer is obviously not the only surgical condition: approximately 30% of the world’s overall disease burden requires surgical decision making.2 Despite this, 4.8 billion people lack access to safe, affordable, and timely surgery and anesthesia.3 Among those who have access, 81 million people per year will, like Sambany, impoverish themselves to get an operation.4 Fewer than 10% of the 313 million operations performed every year are done in LMICs, where 6.1 billion people live.5 Madagascar has 0.6 surgeons, anesthesiologists, and obstetricians per 100 000 people; by comparison, the United States has 63.

Fixing the problem of a lack of access to surgery is daunting, but it is feasible and makes economic sense. The argument against surgery has long been that it is expensive and complex, and that the world should invest its limited health resources in interventions that provide more bang for the buck. Infectious disease has dominated this calculus, in part because certain infectious disease interventions can be delivered vertically. Vaccinations, for example, can be produced in high-income countries before being delivered to more variable-resource areas. This is not true of surgery: the entire means of production—the oxygen, the suction, the electricity, the water, the surgeons, the anesthesiologists, the nurses, the support staff, and the infrastructure itself—must be brought to the patient.

A large body of research has shown, however, that surgery is at least as cost-effective as accepted infectious disease interventions.6 Although it would cost $350 billion over the next 15 years to scale up surgery in LMICs, this cost pales in comparison to the $12.3 trillion in gross domestic product losses that are left on the table if the world does nothing for surgery.7

Scaling up surgery is more than an economic issue; it is necessary. The world will not meet its global health goals without surgery. The United Nations has, for example, committed to lowering maternal mortality to 70 deaths per 100 000 live births. This will be frankly impossible without surgery if nearly 35% of maternal admissions require surgery.8 In addition, cancer mortality will not change without surgery if more than 60% of oncology admissions require surgical intervention.8

Sambany’s tumor was not just an overgrowth of basophilic cells in his face; it was the result of missing infrastructure, a nonexistent workforce, poor surgical provision, a lack of financial risk protection for patients who need care, and the failure of a system to take care of its own. The 2015 Lancet Commission on Global Surgery’s central tenet—that the world deserves universal access to safe, affordable surgery and anesthesia care when needed—was exactly what Sambany did not have.

This is the deeper, underlying, systemic problem that we must solve. Treating the tumor alone is insufficient. Short-term surgical delivery trips to the LMICs do little to help the systems in which they work and, in some cases, do actual harm. Higher complication rates, market distortions for surgeons in host countries, and the possibility of dependency all argue against this model for the delivery of surgical care.9 Instead, the Lancet Commission proposed that nations develop national surgical plans built on 5 pillars: infrastructure, workforce, service delivery (including quality and safety), financing, and information management.10

It is into these pillars that we as practitioners can contribute. Each of us has skills in at least 1 of these areas; each of us is passionate about education, surgical safety, quality, out-of-pocket patient costs, or information management. We leverage these skills in our daily lives in our home countries; we can—and must—leverage them in the LMICs.

Chris O’Brien said, “The one thing you should never do is destroy a patient’s sense of hope.” We have the ability to make hope tangible for individual patients through our direct surgical interventions. However, we can do more. We can see past Sambany’s tumor and past the surgical change we can make in one person’s life. We can, instead, see the opportunity to make hope credible for the future of the health systems to which patients like Sambany must return after we go home.

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Article Information

Corresponding Author: Mark G. Shrime, MD, MPH, PhD, Program in Global Surgery and Social Change, Harvard Medical School, 641 Huntington Ave, Ste 411, Boston, MA 02115 (shrime@mail.harvard.edu).

Published Online: November 3, 2016. doi:10.1001/jamaoto.2016.3086

Conflict of Interest Disclosures: All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

Additional Contribution: We thank the patient for granting permission to publish this information.

Previous Presentation: This article was presented at the American Head & Neck Society Ninth International Conference on Head and Neck Cancer; July 18, 2016; Seattle, Washington.

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