In 2015, the United Nations (UN) General Assembly adopted the 2030 Agenda for Sustainable Development, which consists of 17 Sustainable Development Goals, goal 3 being to “ensure healthy lives and promote well-being for all.”1 The Lancet Commission on Global Surgery 2030 estimated that one-third of all deaths worldwide in 2010 were associated with conditions requiring surgery, more than 4 times the number of deaths from HIV/AIDS, tuberculosis, and malaria combined.2 Two-thirds of the world’s population (90% in low- and middle-income countries) lacks access to basic surgical care, contributing to approximately 80 million disability-adjusted life years annually.2 In addition, disasters—both natural (eg, earthquakes, storms, flooding) and “unnatural” or caused by humans (eg, infrastructure failures, terrorist events, armed conflict)—create mass casualties requiring urgent surgical care for hundreds of thousands of people annually.3,4
The benefits of improved surgical care for both mass-casualty disasters and daily health care have been documented in the UN Sendai Framework for Disaster Risk Reduction5 and the National Surgical, Obstetric, and Anesthesia Plan6 developed by the Lancet Commission on Global Surgery. The converging priorities of surgical and disaster planning indicate that resource integration is key to developing the resilient health care systems necessary to address global surgery needs. An external response (eg, UN, World Health Organization, Red Cross) often arrives too late in mass-casualty events—days to a week or longer—to treat acute injuries that require surgical care within minutes to hours.
Integration of National and International Resources Is Key
In the US, trauma accounts for nearly half of all deaths among those younger than 50 years, and integration of civilian and military resources to improve trauma outcomes has been advocated.4 Trauma and stroke centers have been proven to be associated with reduced morbidity and mortality and improved outcomes for a wide range of conditions, including major trauma, cardiovascular events, complicated childbirth, and acute abdominal conditions.4 A full-service trauma or stroke center provides community prevention programs, enhanced prehospital transport, immediate surgical and intensive care, rehabilitation, personnel training, and research—all as integral parts of the established health care system.
Mass-casualty events also benefit from integration, and thus, simultaneous activation of civilian and military or security personnel and infrastructure.7 The military can rapidly establish mobile field hospitals, linking the trauma or stroke system with a mass-casualty response. Integration of civilian and military resources includes cross-training of personnel and a coordinated field hospital response to mass casualties. Expanding the models of trauma and stroke centers to an integrated civilian and military or security mass-casualty system improves both day-to-day and mass-casualty care.
Improving global surgery requires input from low-, middle-, and high-income countries.8 Health care professionals in low- and middle-income countries can offer clinical expertise and cost-effective solutions to health care challenges; health care professionals in high-income countries offer clinical expertise and technology that support those cost-effective solutions.8,9 An example of expertise sharing is the collaboration between Hawassa University in Ethiopia and the American College of Surgeons (more than a dozen US university medical centers) to train general surgeons in Africa.9 Examples of technology sharing include smartphone and Uber-like motorcycle taxis to improve prenatal and postnatal care in Kenya; drones to deliver blood products, antibiotics, vaccines, and laboratory specimens to remote sites in Ghana and Rwanda; and telemedicine to alleviate unnecessary patient transport and to improve communication in Cabo Verde.9
The National Surgical, Obstetric, and Anesthesia Plan6 provides indicators for assessing progress in global surgery, with targets to be reached by 2030.2 These indicators include: (1) 80% of the population within 2 hours of a facility providing basic surgical care; (2) minimum provider density of 20 per 100 000 population; (3) annual surgical volume minimum of 5000 per 100 000 population; (4) perioperative mortality rate documentation; (5) affordability metrics (100% of the population protected against impoverishing or catastrophic expenditure related to surgery).6
What is less obvious than the targets set are the approaches by which programs can be created and implemented to reach those targets by 2030. By taking a proven existing framework—the trauma and stroke center models—and adapting it to the particular conditions of the region or country concerned, substantial progress in surgical care can be made in less than a decade. By integrating all health care resources—civilian, military and/or security, nongovernmental organizations, as well as national and international organizations (eg, UN, World Health Organization)—more efficient use of limited resources can be realized.4,7-9 By making the health care infrastructure more mobile and resilient (eg, battery-powered computed tomography, portable operating rooms), areas where power outages are routine and logistics are difficult can provide more consistent surgical care, as well as respond to mass casualties.9 By sharing expertise and technology across low-, middle- and high-income countries, the global surgical talent pool can be tapped for innovative solutions that benefit care in all countries.8,9
Achieving Indicators of Progress in Surgical Care
Examples from 3 countries illustrate different ways to improve surgical care and health care in general. In Rwanda, Partners in Health has collaborated with the government to create the University of Global Health Equity. In less than 7 years, students with a secondary or high school diploma can be awarded the joint degrees of Bachelor of Medicine and Surgery and Master of Science in Global Health Delivery. As the university’s website states, this program “equips future physicians with state-of-the-art clinical knowledge and know-how, as well as the skills needed to effectively implement innovative public health solutions, lead and manage equitable health systems, and improve the delivery of care in communities across the globe.”10 In Chile, the government has created a National Office of Emergencies to foster collaboration among the nation’s civilian and military emergency response resources.9 In Pakistan, Tariq Khan, a neurosurgeon, began community education for trauma prevention more than 2 decades ago,9 followed by a rehabilitation center focused on spinal cord injury, 2 hospitals, schools of medicine and nursing, and an ambulance service. Future plans include collaboration with the military for improved daily and emergency care, a national Pakistani trauma registry, and implementation of the National Surgical, Obstetric, and Anesthesia Plan in Pakistan.
Less than a decade remains to reach the UN Sustainable Development Goals for 2030. An approach integrating all health care resources in each country or region, with collaboration among personnel and national and international health care organizations from low-, middle-, and high-income countries, can build on the proven models of trauma and stroke centers to expand global surgery rapidly, thus saving the one-third of lives presently being lost worldwide to a lack of surgery.
Published: June 25, 2021. doi:10.1001/jamahealthforum.2021.1213
Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Andrews RJ et al. JAMA Health Forum.
Corresponding Author: Russell J. Andrews, MD, NASA Ames Research Center, Moffett Field, CA 94035 (firstname.lastname@example.org).
Conflict of Interest Disclosures: None reported.
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Andrews RJ, Rosenfeld JV, Crisp N. The Importance of Surgical Care to Achieve the United Nations Sustainable Development Goal for Healthy Lives by 2030. JAMA Health Forum. 2021;2(6):e211213. doi:10.1001/jamahealthforum.2021.1213