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Invited Commentary
Global Health
January 11, 2019

From Measuring Disease Burden to Designing and Evaluating Solutions—Global Surgery Research in Evolution

Author Affiliations
  • 1Division of Trauma and Surgical Critical Care, Department of Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, Pennsylvania
  • 2Department of Surgery, Soroti Regional Referral Hospital, Soroti, Uganda
  • 3Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
JAMA Netw Open. 2019;2(1):e186840. doi:10.1001/jamanetworkopen.2018.6840

Over the past decade, incredible advances in the field of global surgery have been made. In 2015, The Lancet Commission on Global Surgery report highlighted the significant unmet need for safe and affordable surgical care for the world’s people.1 In the same year, the authors of the third edition of Disease Control Priorities in Developing Countries outlined a plan for capacity building for essential surgery,2 while the 68th World Health Assembly passed a resolution to strengthen emergency and essential surgical and anesthesia care as a component of universal health coverage.3 Today, we recognize that the provision of safe and effective surgical care is necessary to meet the Sustainable Development Goals4 by 2030. This is an exciting time to be part of the field of global surgery as we strive to achieve equity in the provision of surgical care for all.5

Pediatric surgical conditions account for an important, yet often underrecognized, portion of the global surgical disease burden. Concepcion and colleagues6 assessed 1503 children for surgical conditions using the Surgeons OverSeas Assessment of Surgical Need (SOSAS) survey. In this cross-sectional study using a national community-based sampling survey, the authors found a pediatric surgical condition prevalence of 12.2%, with just 23.7% of these cases treated by surgery. The most common conditions found among children in Somaliland were congenital anomalies (33.8%) and wounds secondary to injury (24.6%). The findings of this study echo previous investigations of pediatric surgical disease burden in other low- and middle-income countries (LMICs),7-9 and this article represents a significant addition to the literature on the global burden of surgical disease. For policy makers, the study results provide an important reminder that specific provisions for the surgical care of children must be part of any national surgical, obstetric, and anesthesia plan going forward.

While this study was well designed and executed, the use of the SOSAS tool as administered by nonphysician surveyors introduces limitations in the utility of its results. First, the SOSAS tool does not provide information about surgical conditions that is granular enough to identify resources needed to address the conditions identified. For example, a wound secondary to injury if superficial could be repaired by an associate clinician, while a deep laceration with associated orthopedic or vascular injury would likely require a surgical specialist for optimal care. Similarly, a burn that is partial thickness involving a small body surface area may just need local wound care, while a large full-thickness burn that does not receive timely resuscitation, excision, and skin grafting could result in infection, contracture, and permanent disability or death. Because the SOSAS tool does not assess the level of disability caused by each surgical condition found, the implications of the disease prevalence demonstrated by the survey for population health are unclear.

This study by Concepcion and colleagues6 represents the most recent addition to a growing body of evidence that clearly demonstrates a significant disease burden of pediatric surgical conditions in LMICs, now including Somaliland, Uganda, Rwanda, Sierra Leone, and Nepal.7-9 In the future, we would like to see similar epidemiologic studies include more specific condition diagnoses, measures of associated morbidity, and physical examination by a skilled health care professional. A local pediatric or general surgeon familiar with pediatric surgical conditions would be ideal. This would allow for more accurate assessment, as well as an opportunity for surgical intervention. Repetition of the SOSAS survey alone, without physical examination, diagnosis, and intervention when needed, carries ethical concerns. The survey respondents do not benefit much from receiving a possible diagnosis but no access to treatment. As a tool for advocacy and generating initial data on the global burden of surgical disease, the SOSAS survey has certainly been useful; however, as a tool to guide health policy and planning going forward, it remains limited.

The field of global surgery research is actively evolving. The earliest research focused mainly on defining the global surgical disease burden for the purposes of advocacy. Essential surgical care is now increasingly recognized as a key component of primary health care by the global health community. Therefore, it is important now to take the next step and find solutions to the challenges of scaling high-quality surgical care globally. Children with correctable, often curable, conditions should not be kept waiting any longer. To increase access to safe and effective surgical care for children, activities within the 3 pillars of global surgery—practice, research, and advocacy—should be targeted toward this goal.5 Surgical care for children requires specialized training, facilities, and supplies, which are often missing in LMICs. Policy makers need to hear from experts and researchers the exact tools, services, infrastructure, and workforce needed to address essential pediatric surgical conditions in their specific contexts. A research agenda for congenital anomalies has been suggested in the third edition of Disease Control Priorities10 and includes registries for specific conditions, capacity assessment for surgical care, development of models for integration of pediatric surgical services into existing child health initiatives, and cost-effectiveness analyses. Ultimately, clinicians and researchers need to strive to design and evaluate the effectiveness and outcomes of capacity-building programs for pediatric surgical care. Finally, ongoing efforts to advocate for children with surgical conditions with specific data that can be used to formulate policy are required. With limited funding for research in global surgery, studies that provide some benefit to patients, members of the surgical workforce, or health systems in LMICs should be considered the criterion standard going forward. The time has come to reframe the focus of global surgery research from measuring the problem to identifying and evaluating solutions to the most pressing challenges facing the field.

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Article Information

Published: January 11, 2019. doi:10.1001/jamanetworkopen.2018.6840

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2019 Beard JH et al. JAMA Network Open.

Corresponding Author: Jessica H. Beard, MD, MPH, Division of Trauma and Surgical Critical Care, Department of Surgery, Lewis Katz School of Medicine at Temple University, 3401 N Broad St, Fourth Floor, Zone C, Philadelphia, PA 19140 (jbeard08@gmail.com).

Conflict of Interest Disclosures: None reported.

References
1.
Meara  JG, Leather  AJ, Hagander  L,  et al.  Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.  Lancet. 2015;386(9993):569-624. doi:10.1016/S0140-6736(15)60160-XPubMedGoogle ScholarCrossref
2.
Mock  CN, Donkor  P, Gawande  A, Jamison  DT, Kruk  ME, Debas  HT; DCP3 Essential Surgery Author Group.  Essential surgery: key messages from Disease Control Priorities, 3rd edition.  Lancet. 2015;385(9983):2209-2219. doi:10.1016/S0140-6736(15)60091-5PubMedGoogle ScholarCrossref
3.
World Health Organization. Emergency and essential surgical care: Events World Health Assembly. http://www.who.int/surgery/wha-eb/en/. Accessed November 14, 2018.
4.
World Health Organization. Sustainable Development Goals. https://www.un.org/sustainabledevelopment/sustainable-development-goals/. Accessed November 14, 2018.
5.
Dare  AJ, Grimes  CE, Gillies  R,  et al.  Global surgery: defining an emerging global health field.  Lancet. 2014;384(9961):2245-2247. doi:10.1016/S0140-6736(14)60237-3PubMedGoogle ScholarCrossref
6.
Concepcion  T, Mohamed  M, Dahir  S,  et al; Global Initiative for Children’s Surgery.  Prevalence of pediatric surgical conditions across Somaliland.  JAMA Netw Open. 2019;2(1):e186857. doi:10.1001/jamanetworkopen.2018.6857Google Scholar
7.
Butler  EK, Tran  TM, Nagarajan  N,  et al; SOSAS 4 Country Research Group.  Epidemiology of pediatric surgical needs in low-income countries.  PLoS One. 2017;12(3):e0170968. doi:10.1371/journal.pone.0170968PubMedGoogle ScholarCrossref
8.
Petroze  RT, Calland  JF, Niyonkuru  F,  et al.  Estimating pediatric surgical need in developing countries: a household survey in Rwanda.  J Pediatr Surg. 2014;49(7):1092-1098. doi:10.1016/j.jpedsurg.2014.01.059PubMedGoogle ScholarCrossref
9.
Groen  RS, Samai  M, Petroze  RT,  et al.  Household survey in Sierra Leone reveals high prevalence of surgical conditions in children.  World J Surg. 2013;37(6):1220-1226. doi:10.1007/s00268-013-1996-7PubMedGoogle ScholarCrossref
10.
Farmer  D, Sitkin  N, Lofberg  K, Donkor  P, Ozgediz  D. Surgical interventions for congential anomalies. In: Debas HT, Donkor P, Gawande A, Jamison DT, Kruk ME, Mock CN, eds. Essential Surgery. Vol. 1 of Disease Control Priorities. 3rd ed. Washington, DC: World Bank; 2015. http://dcp-3.org/chapter/1769/surgical-interventions-congenital-anomalies. Accessed December 3, 2018.
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