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Surgical digest

The development and future of global surgery as a field of research

Jenny Löfgren, MD PhD

Department of Molecular Medicine and Surgery
Karolinska Institute
Karolinska University Hospital
Department of reconstructive plastic surgery,
Karolinska University Hospital
Stockholm, Sweden

Jenny Löfgren, MD PhD

Surgical conditions and surgical healthcare exist in all parts of the world, in countries of all income levels. This is not new. Global surgery as a concept and research field, however is. Most ideas and innovations take time to become established1. This applies also to the notion that surgical conditions and surgical health care are important from the perspective of population health and health care systems everywhere. Figure 1 shows the process of the diffusion of new ideas and innovations into a larger audience, in this case the research community. Global surgery is the idea.

Figure 1. Diffusion of innovations and ideas

The innovators of the past

In 1980, Halfdan Mahler who was the Director General of the WHO, stated that “the vast majority of the world’s population has no access whatsoever to skilled surgical care and little is being done to find a solution. I beg of you to give serious consideration to this most serious manifestation of social inequity in health care2. Research was essential to define and measure the problem from both the epidemiological and societal perspective. There was a dire need to test innovative solutions to solve the problem of inadequate quantity and quality of surgery so that evidence based, and contextually adequate interventions could be put in place. However, very little research was undertaken. Instead, numerous opinion pieces, letters to the editors and descriptions of surgical missions were published. The tone was frequently that of the surgeon hero – or surgeon saviour, of less fortunate populations, preferably with photos of the surgeon and some of their patients, in particular children or patients with advanced diseases. The number of procedures performed over a short interval, and minimal information about outcomes characterized this era.

One of the very few exceptions was Dr Nordenberg who published research on surgery from different angles, in eastern Africa in the 80’s to the early 2000’s. He and partners measured the burden of disease due to selected conditions and the unmet need for surgery. They carried out qualitative research to assess patient attitudes towards surgery, impact of user fees and also sought to find ways to assess the performance of the health care system, among other things3,4.

A research agenda for surgery in eastern Africa was proposed in 19905:

(a) population-based output of major and minor operations by country and region;

(b) outcome after a few selected operations;

(c) availability and use of surgery-related resources such as manpower, equipment and supplies;

(d) assessment of needs for surgery using household health survey methods.

The present – visionaries, pioneers and the tipping point

The work of visionaries and pioneers in global surgery resulted in the Lancet commission of global surgery and their ground-breaking, evidence-based, report in 2015. A goal was identified: “universal access to safe, affordable surgical and anaesthesia care when needed”. A research agenda was outlined of which the following five were at the highest priority level6:

1. Cost and financing;

2. Quality and safety;

3. Care delivery and innovations;

4. Burden of disease;

5. Determinants and barriers.

In the same year, the Disease Priorities Project in 2015 included an entire volume about Essential Surgery7. The 2015 WHA68.15, “Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage (UHC)8. These advances and the associated publicity resulted in a tsunami of increased interest and the idea of global surgery reached a tipping point.

Numerous academic global surgery groups have been established. Increasingly many students and health care professionals find interest in global surgery, and large collaborative networks have formed. The funding situation has improved and high-ranking, scientific journals, have started publishing the manuscripts of global surgery researchers.

From the scientific perspective, a lot of work has circulated around measuring surgical output, need, consequences of unmet need and mostly short-term outcomes of surgery for various conditions. Model-based studies have been carried out to assess different topics of interest on regional and global scale. Thanks to the contribution of an increasing number of researchers, research groups and collaborative networks, the body of scientific evidence within the global surgery field has grown exponentially during the past 10-15 years.

The future – movement of the masses and down to details

Most of the work to achieve the goals of global surgery in general and of the global surgery research agenda in particular remains to be done. This will require the work of many and a near complete diffusion of the idea that “surgery is an indivisible, indispensable part of health care6.

Additional ideas that need to be adopted are that:

1. There are no simple solutions to the problem of lack of quality surgical health care and the immense burden of disease due to surgical conditions;

2. The idea that a lot can be achieved with a little is misleading. A lot can be done, with adequate resources, is more correct. In reality, large financial investments as well as an enormous amount of dedicated work over long periods of time are required to meet the goal of surgery for all when needed, at an affordable cost.

A research agenda for the future

The future research agenda should focus on solutions to the global surgery problems that have been identified and measured. Answering even fairly simple questions such as which surgical method to use, and who should perform which surgeries, takes several years of planning and evaluation. For this we need clinical trials and prospective cohort studies with long term follow-up of patients. We need to build registers for various conditions and their treatments.

The bulk of surgical and anaesthesia services are provided outside university level hospitals and academic institutions. What happens in terms of clinical work and research at district level and regional referral level hospitals is key to the future of global surgery.

In order to progress the clinical research agenda towards solutions, setting specific research with high granularity and precision is needed. This means that there is a need for detailed investigations also on a smaller scale where solutions to improve quantity and quality of surgery and anaesthesia care can be tested in rigorous ways in clinical settings. It is unreasonable to expect that each research project carried out must be representable of low- and middle-income countries (LMIC) as a collective. After all, these countries are very diverse and house 80% of the world’s population.

In addition to clinical research, much remains to be investigated from the public health perspective such as prevention strategies, health systems research including human resource issues, and health economical evaluation of surgical health care services. These areas of research provide an important bridge between clinical research and practice to advocacy and policy making. The research must provide results in a language that decision makers, international organizations and similar can understand and act on.

The global surgery researcher of the future

Many of the truly global surgeons are very local, practicing in lower-level health care units, sometimes in hard-to-reach locations. Oftentimes, these surgical providers cannot access the research community due to barriers such as cost, distance and challenging work environment. Yet, these colleagues are central to reach the global surgery goals. Targeted efforts to engage them in research that can be carried out in their clinical environment should be promoted. This goes very well in hand with the above-mentioned need for research with high granularity and precision. In addition, such a set-up is very useful for research training.

Investigator-initiated research by professionals practicing in the countries, health care systems and hospitals under study is important. It will make sure that the specific research priorities are made in a well-informed way. These people know their communities which is important for research implementation and follow-up. They can also facilitate that the results of the research can come to use in clinical practice with minimal delay.

Consequently, a critical number of independent researchers is needed. Providing research training for surgical and anaesthesia providers is a very important task to take on. This is a costly, tedious, slow-fix to the lack of representation in surgery research from low- and middle income countries.

Dear future researcher

We warmly welcome you to the global surgery research community! This community is a vibrant one with endless possibilities to participate in meaningful research. You have the option of working on topics relevant for a variety of conditions, people, health care systems and countries. A very pleasant feature of this research community is the openness and understanding that there is so much work to be done that there is no need for competition. Instead, partnership and collaboration define global surgery research. Your dedicated work is very much needed and we are very eager to partner with you!


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