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“Two roads diverged in a wood, and I—
I took the one less traveled by,
And that has made all the difference.”
From The Road Not Taken ~ Robert Frost
To paraphrase Robert Frost’s The Road Not Taken, global surgical care has taken a road less traveled, and it has indeed made a difference. Yet, traveling this road has not necessarily been a good thing [1].
To some, the journey toward global surgical equity began in 2008 with an article by Drs. Farmer and Kim [2]. Additional strides were made in 2015 with Resolution WHA68.15 [3], and the release of the Lancet Commission on Global Surgery (LCoGS) report which attempted to provide a unifying vision [4].
The LCoGS also took us down the “less traveled road” by focusing on the lack of access of five billion people to surgical care. The dilemma is that no other global health condition (e.g., maternal and child health, HIV, malaria, etc.) frames the magnitude of their problem in terms of access to care. Global health conditions are routinely measured by incidence, prevalence, annual death rates, unmet need, and/or disease burden. Before the establishment of the LCoGS, researchers characterized surgical need as 12–25% of the global disease burden [5]. These numbers were reinforced by numerous community-based surveys of surgical need [6, 7]. Highlighting access depicts the global surgical care problem as orders of magnitude greater than other conditions. In defining the lack of access to surgical care, many global surgery proponents cite the affected population in billions rather than millions. Aside from an inequivalent comparison, this appears to create a more prominent role for surgical care than for other conditions. Surgical care is not more important than any other specialty or intervention, but rather part of the whole system.
So, what can be done to get back on track? First, let us agree to stop defining the magnitude of the problem of surgical care as a lack of access for five billion people. If we are to speak about access issues, we must also acknowledge that billions lack access to non-surgical care. Instead, let us change roads and address the unmet need and surgical disease burden. Let us agree for now to use the estimate that 143 million additional operations are needed annually [8], and 1.5 million people die each year from a lack of surgical intervention and treatment [9]. It also seems prudent to stop comparing the surgical disease burden with other disease conditions. On an individual basis, a patient ill because of a disease caused by HIV or malaria or tuberculosis, or the clinician treating them, does not really care that more people in the world would benefit from greater resources devoted to increasing surgical care. Nevertheless, these patients may develop a concomitant surgical condition and would benefit from treatment using a holistic non-surgical and surgical perspective.
Moving forward, we should diverge from the “road less traveled” and step back on to the more familiar road by reframing the problem based on the annual number of additional operations needed and not performed. We should further estimate the number of people who die annually because of conditions possibly preventable with surgical interventions. It is not realistic or appropriate to assume Global North institutions and systems should lead the processes to address the shortfalls in surgical care in low- and middle-income countries (LMIC). Better solutions and a new perspective are required. Existing assessments of surgical capacity may not correlate with delivery of essential surgical care [10], so efforts are needed to determine how to deliver the right care to the right people at the right time. These efforts should be driven by surgical experts in LMIC who have the most at stake.
Surgical care for underserved populations is currently on a road less traveled. While some progress is nevertheless occurring, a course correction away from focusing on the lack of access to care is due. We must rejoin the main road and speak the same global health language as the majority of global health professionals working across disciplines for equitable health care.
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Drs. Wren and Kushner are paid consultants for the Intuitive Foundation’s Global Surgical Training Challenge.
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Ewbank, C., Derbew, M., Ratnayake, A. et al. Global Surgery: The Road Less Traveled and How to Get Back on Track. World J Surg 47, 1090–1091 (2023). https://doi.org/10.1007/s00268-023-06920-x
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DOI: https://doi.org/10.1007/s00268-023-06920-x