Defining the what, building the how: a call for integrated guidance in global surgery

Correspondence to: Nicolò Marchesini (e-mail: nicolo.marchesini@aovr.veneto.it)

Azienda Ospedaliera Universitaria Integrata Verona

Department of Neurosurgery

Verona

Italy

BJS, https://doi.org/10.1093/bjs/znae024, published 19 February 2024

We read with great interest the article by McKnight et al. defining humanitarian surgery through an international Delphi consensus1. This work represents a crucial step in bringing clarity to a field often characterized by heterogeneous definitions and practices. The authors established a common language adopting a rigorous process and provided a foundation upon which a more effective, accountable, and professional global surgical care can be built.

Their definition of Humanitarian Surgery emphasizes the importance of delivering emergency surgical care in accordance with core humanitarian principles: humanity, neutrality, impartiality, and independence. Furthermore, they underscore the importance of multidisciplinarity, coordination with local systems, and the use of standardized data and protocols. These elements have been highlighted as essential for ensuring quality and accountability in some of the world's most challenging environments.

This work resonates well with parallel efforts in global surgery, specifically within the global neurosurgical field. Recently, the European Association of Neurosurgical Societies (EANS) Global and Humanitarian Neurosurgery Committee published a set of recommendations for sustainable neurosurgical partnerships between European institutions and partners in low-resource settings. Their development adopted a systematic approach through qualitative interviews with balanced representation from both high-income countries (HICs) and low- and middle-income countries (LMICs), followed by expert consensus. These 22 recommendations provide a practical framework for initiating, developing, and maintaining equitable collaborations2,3.

In other words, while McKnight et al. define what humanitarian surgery is and where it should be delivered, the EANS recommendations focus on how to build the institutional partnerships that underpin sustainable surgical care delivery in resource-limited settings. Highlighted key-principles include prioritizing trust and communication; avoiding paternalistic dynamics; ensuring joint planning with mutually agreed objectives; and focusing on long-term sustainability through progressive independence of the LMIC partner. These principles are transversal and not specialty-specific: they apply equally to all fields of global surgery and-plausibly-global health.

The convergence of these two initiatives highlights an important opportunity: defining humanitarian surgery establishes the scope and standards for clinical care; developing and maintaining sustainable partnerships creates the infrastructure and relationships needed to deliver that care effectively and ethically.

We wish to highlight that neither field can achieve its goals in isolation and we suggest to see these two frameworks as interconnected components of a unified vision for global surgery. The EANS recommendations offer practical guidance that can inform how humanitarian surgical teams, as defined by McKnight et al., establish and maintain their relationships with local health systems and governments. On the other hand, the clarity provided by the humanitarian surgery definition can help neurosurgical partnerships understand when their capacity-building work transitions into humanitarian response.

Building on this synergy, we propose to convene a broader, multi-stakeholder consensus process that brings together diverse experts from different surgical specialties, humanitarian organizations, and LMIC partners. The goal is to develop an integrated framework that unifies the definition of humanitarian surgery with the principles of sustainable partnership, creating guidance that is truly multidisciplinary and globally applicable. Such a framework would support not only surgeons but all providers working to deliver ethical, effective care in resource-limited and crisis settings.

We congratulate McKnight and colleagues on their important contribution and look forward to collaborating with the global surgery community to advance this shared agenda.