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Surgery_Schwartz. 100,000 population in LMICs by 2030. This figure must be compared to the U.S. $20.7 trillion loss in global economy that surgical conditions would be responsible for.Recent studies have shown that essential surgical condi-tions account for about 18% of the global burden of disease. Investment in essential surgical services is critical and should be done early in the path towards universal health coverage (UHC). The barriers to essential surgical services in LMICs are formi-dable. The shortage in surgical workforce is huge, and it is clear that the deficit cannot be satisfactorily addressed without task sharing. Infrastructure deficits (clinics, hospitals, equipment, drugs, blood banks, etc) are equally enormous. The first (district) hospital is the important platform for delivery of essential surgical services. The DCP3 estimates that it would cost U.S. $43 million annually of additional spending to provide universal coverage of essential surgery applicable to first-level hospitals


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Surgery_Schwartz. surgical services. The DCP3 estimates that it would cost U.S. $43 million annually of additional spending to provide universal coverage of essential surgery applicable to first-level hospitals worldwide.Outreach and EngagementMany models for outreach and engagement have had a positive impact on the accessibility of surgery. Organizations participat-ing in outreach are guided by a wide range of motivations and resources (Fig. 49-13). Some organizations are purely humani-tarian and service oriented; others are primarily educational. Some even use the promise of healthcare to advance political, religious, or personal agendas.Many patients have benefited from the multitude of service-oriented volunteer “missions” providing much needed surgical care that would otherwise have been unavailable. While volun-teerism and medical missions provide needed clinical surgical care for underserved populations, they may not be a sustainable solution to long-term manpower shortages for health.75


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Surgery_Schwartz. While volun-teerism and medical missions provide needed clinical surgical care for underserved populations, they may not be a sustainable solution to long-term manpower shortages for health.75 Com-prehensive initiatives are necessary to engage local healthcare professionals and organizations, governments, and academic institutions to build sustainable capacity.76Charitable Surgical Delivery Platforms. A significant bur-den of surgical disease is addressed through charitable organi-zations. The DCP3 divides these charitable surgical delivery platforms into two types: temporary delivery platforms and spe-cialty surgical hospitals (Table 49-3).77Short-term charitable surgical platforms bring entire surgi-cal teams along with equipment and supplies needed to operate in local facilities for a short period of time. Local physicians provide the majority of follow-up care.78-80 Self-contained plat-forms bring the entire surgical infrastructure (fully functional operating rooms, postoperative


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Surgery_Schwartz. short period of time. Local physicians provide the majority of follow-up care.78-80 Self-contained plat-forms bring the entire surgical infrastructure (fully functional operating rooms, postoperative recovery capability) through various modes of transportation: airplanes, ships, trucks, and buses. These self-contained platforms tend to stay in-country longer, may still provide short-term care, and tend not to leave behind any physical structure.78,80,81Little information exists on outcomes and cost-effectiveness of these temporary surgical platforms. Where no other services Politicians/AdministratorsResourcesFinancialHumanPoliticalMotivationsHumanitarianEducationalAcademicPoliticalOtherCataractHerniaVesico-vaginalfistulaLaparoscopicsurgeryEducatorsIndividualpeopleHealthcareprovidersCountryProvinceUrban vs.RuralDisease(technique specific)GeographicTargeted audienceGlobalsurgery initiativesPoliticians/administratorsFigure 49-13. Global surgery initiatives. (Reproduced with permission


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Surgery_Schwartz. vs.RuralDisease(technique specific)GeographicTargeted audienceGlobalsurgery initiativesPoliticians/administratorsFigure 49-13. Global surgery initiatives. (Reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 208713/02/19 5:54 PM 2088SPECIFIC CONSIDERATIONSPART IIexist, they may provide needed services. However, some of these charitable organizations report higher complications rates in lower-resource settings, which seem to increase even more with complex procedures. Some of these platforms include edu-cation for local care providers along with clinical care. While some question their ability to sustainably train local surgical teams, one charitable partnership with short-term, concentrated surgical training trips over 9 years documented a countrywide transition from open cholecystectomy to laparoscopic cholecys-tectomy in Mongolia.82Specialty surgical hospitals establish entire hospitals or facilities within existing hospitals. Some target


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Surgery_Schwartz. transition from open cholecystectomy to laparoscopic cholecys-tectomy in Mongolia.82Specialty surgical hospitals establish entire hospitals or facilities within existing hospitals. Some target specific diseases (Addis Ababa Fistula Hospital) while others provide a wide range of surgical and medical services (Pan-African Academy of Christian Surgeons [PAACS] mission hospitals); many are supported through partnerships with various charitable and gov-ernmental organizations.77International OrganizationsUnited Nations. Committed to maintaining international peace, developing friendly relations between nations, and promoting better standards of living (conquering hunger, dis-ease, and illiteracy) and human rights, representatives from 51 nations in 1945 signed the United Nations (UN) Charter at the United Nations Conference on International Organization in San Francisco, California.83 There are now 193 member states.84 The UN promotes a social justice agenda advocating for world-wide


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Surgery_Schwartz. at the United Nations Conference on International Organization in San Francisco, California.83 There are now 193 member states.84 The UN promotes a social justice agenda advocating for world-wide health, engagement of philanthropies, and civil society in global health initiatives, and it supports the sustainable develop-ment goals (SDGs).85Sustainable Development Goals. In September 2000, the UN led a worldwide, organized effort to set benchmarks for social, economic, and environmental development. Leaders from 189 countries agreed on eight specific “millennium devel-opment goals” (MDGs), spanning poverty, mortality, education, sustainability, and development.86The MDGs created a framework for improvement that some criticized as unattainable; nevertheless nearly 1 billion people were lifted out of extreme poverty, and primary education for girls made measurable improvements.87 Still, many challenges, including some related to lack of surgical care, remained. In 2015, the UN General


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Surgery_Schwartz. out of extreme poverty, and primary education for girls made measurable improvements.87 Still, many challenges, including some related to lack of surgical care, remained. In 2015, the UN General Assembly reconvened to raise the bar yet again, in what was declared a “supremely ambitious and transforma-tive vision.”88 Eight MDGs became 17 SDGs with 169 specific targets, to be achieved by 2030 (Table 49-4).85 Most relevant to the global surgeon is SDG #3, “good health and well-being,” which builds upon the MDGs’ primarily maternaland child-mortality focus, as well as communicable disease prevention. SDG #3 broadens the focus to nine health targets, including a one-third reduction in deaths by noncommunicable diseases, as well as halving the rate of deaths and injuries from road traffic accidents by 2020. In addition, a novel push to strengthen and retain the global health workforce and systems for protection and prevention of disease also falls squarely within the realm of the surgical


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Surgery_Schwartz. by 2020. In addition, a novel push to strengthen and retain the global health workforce and systems for protection and prevention of disease also falls squarely within the realm of the surgical provider. Finally, the SDGs have garnered praise for closely involving local stakeholders, versus the expert consensus that produced the MDGs. Funding to work towards achievement of the SDGs is also divided between wealthier and poorer nations, whereas the MDGs relied primarily on funding from HICs to sup-port their mission.89World Health Organization. The initial UN Conference in 1945 voted to establish a new international health organization. The Constitution of the World Health Organization (WHO) was approved and ratified in 1948.83 The first World Assembly in 1948 established malaria, tuberculosis, venereal diseases, maternal and child health, sanitary engineering, and nutrition as WHO priorities. One of the WHO’s greatest public health sto-ries is the worldwide eradication of smallpox that


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Surgery_Schwartz. venereal diseases, maternal and child health, sanitary engineering, and nutrition as WHO priorities. One of the WHO’s greatest public health sto-ries is the worldwide eradication of smallpox that began with the USSR proposal for the WHO-led program in 1958 culminating in the last identified case in Somalia in 1977.While the disease burden from communicable diseases has abated in large part from these successful international coopera-tive interventions, little has been done to address the growing global burden of surgical disease. Despite the laudable aims of the 1978 Declaration of Alma Alta, which expressed the need for urgent action for the world community to protect and pro-mote health for all people, the declaration did so by crowning primary health care as the key to achieving the goal of health for all—which was then accepted by the member countries in the World Health Organization.90 Although the Alma Ata slogan Table 49-3Examples of charitable surgical delivery


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Surgery_Schwartz. the goal of health for all—which was then accepted by the member countries in the World Health Organization.90 Although the Alma Ata slogan Table 49-3Examples of charitable surgical delivery platformsTemporary DeliveryShort-Term Trips World Surgical Foundation Kenya Orthopedic Program APRIDEC Medical Outreach Group Self-Contained Mobile Surgical Platforms Mercy Ships Cinterandes FoundationSpecialty Surgical Hospitals Addis Ababa Fistula Hospital Aravind Eye Hospital Mission Hospitals (PAACS*)*Pan-African Association of Christian hospitalsTable 49-4Sustainable development goals 1No poverty 2Zero hunger 3Good health and well-being 4Quality education 5Gender equality 6Clean water and sanitation 7Affordable and clean energy 8Decent work and economic growth 9Industry, innovation, and infrastructure10Reduced inequalities11Sustainable cities and communities12Responsible consumption and production13Climate action14Life below water15Life on land16Peace, justice, and strong


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Surgery_Schwartz. and infrastructure10Reduced inequalities11Sustainable cities and communities12Responsible consumption and production13Climate action14Life below water15Life on land16Peace, justice, and strong institutions17Partnerships for the goalsBrunicardi_Ch49_p2077-p2112.indd 208813/02/19 5:54 PM 2089GLOBAL SURGERYCHAPTER 49“health for all by 2000” did not materialize, it did galvanize efforts for global partnerships for healthcare improvements and poverty reduction. In 2015, the World Health Assembly (WHA) published resolution WHA 68.15, which proclaimed surgical and anesthesia care as a crucial component of primary care worldwide—for the first time in history. The resolution urged member states to complete nine actions, including prioritizing a core set of emergency and essential surgery and anesthesia services at the primary care level, ensuring access to essential medications and infection control techniques, and developing policies for providers’ minimum skills, among others.


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Surgery_Schwartz. and anesthesia services at the primary care level, ensuring access to essential medications and infection control techniques, and developing policies for providers’ minimum skills, among others. Addition-ally, the Director-General of the WHO was asked to complete ten actions related primarily to policyand advocacy-related endeavors at the international level. The resolution was voted in unanimously by 194 member states.91The Violence and Injury Prevention Program (VIP) and the Global Initiative for Emergency and Essentials Surgical Care (GIEESC) are two programs related to surgery within the WHO that began before 2008. But as a response to a growing recognition of the significant unmet surgical need, in 2008 the WHO for the first time included basic surgery as a component for community primary health care (Fig. 49-14).92The Global Initiative for Emergency and Essential Surgical Care. The Clinical Procedures (CPR) team in the WHO Department of Essential Health Technologies (EHT)


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Surgery_Schwartz. primary health care (Fig. 49-14).92The Global Initiative for Emergency and Essential Surgical Care. The Clinical Procedures (CPR) team in the WHO Department of Essential Health Technologies (EHT) convened a multidisciplinary group of experts from various surgical disci-plines, professionals, and civic leaders from national and inter-national organizations, as well as representatives from various WHO departments, in December 2005 in Geneva, Switzerland to formally organize the Global Initiative for Emergency and Essential Surgical Care (GIEESC).93 GIEESC’s main aim was to assist member states with capacity strengthening in the safe Waste disposalinspectionMammographyAlcoholismHerniaPlacentapraeviaTrafficaccidentConsultantsupportReferral formulti-drugresistanceReferral forcomplicationsGenderviolenceSurgeryMaternityEnvironmental health labTraining centreTrainingsupportCancerscreeningcentreWomen’sshelterAlcoholicsanonymousCommunitymentalhealth unitEmergencydepartmentHospitalSpecialized


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Surgery_Schwartz. health labTraining centreTrainingsupportCancerscreeningcentreWomen’sshelterAlcoholicsanonymousCommunitymentalhealth unitEmergencydepartmentHospitalSpecialized careDiagnosticservicesTB controlcentreDiabetes clinicCTscanCytologylabDiagnostic supportPap smearsSelf-helpgroupLiaisoncommunityhealth workerOtherOtherSocialservicesNGOsSpecialized prevention servicesCommunityPrimary-care team:continuous,comprehensive,person-centred careFigure 49-14. Emergency and essential surgery: an integral component of primary care. (Reproduced with permission from The World Health Report 2008—primary Health Care (Now More Than Ever). http://www.who.int/whr/2008/en/.)Mongolia GIEESCThe WHO situational analysis tool, developed in 2007 to assess the availability of emergency and essential surgical care (EESC) at individual health facilities, has been utilized to document limited infrastructure, human resources, procedures, equipment, and supplies available for even basic EESC in many countries.95 For example,


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Surgery_Schwartz. health facilities, has been utilized to document limited infrastructure, human resources, procedures, equipment, and supplies available for even basic EESC in many countries.95 For example, there were no trained surgeons or anesthetists at 44 first-referral hospitals in Mongolia.3 Only 66% of the facilities had electricity, and 45% had running water (Fig. 49-15).Most facilities lacked any policy for EESC, disaster preparedness, basic equipment to provide EESC, or any and appropriate use of emergency and essential surgical care (procedures, equipment) at resource-limited healthcare facilities through training and education programs. The training program was built around the WHO Integrated Management of Emer-gency and Essential Surgical Care (IMEESC) tool kit.94 The tool kit included best practice protocols, guidelines on policies, training curriculum, emergency equipment, teaching slides, and monitoring and evaluation instructions. Additionally, low-cost editions of the manual Surgical


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Surgery_Schwartz. protocols, guidelines on policies, training curriculum, emergency equipment, teaching slides, and monitoring and evaluation instructions. Additionally, low-cost editions of the manual Surgical Care at the District Hospital have been made available in local languages. As of 2015, GIEESC had over 2100 members in 140 countries.95 A Mongolian edition facilitated early expansion of GIEESC throughout the country. Mongolia has improved basic infrastructure, human resources, and capabilities; and the use of the tool kit system has led to its incorporation into the countrywide healthcare plan96 (Box: Mongolia GIEESC).Brunicardi_Ch49_p2077-p2112.indd 208913/02/19 5:54 PM 2090SPECIFIC CONSIDERATIONSPART IIFigure 49-15. First Level (Soum) Hospital (left); Suturing of lacerated tongue by natural light (right). (Reproduced with permission from Intermountain Healthcare. Photo contributor: Raymond R. Price,


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Surgery_Schwartz. 49-15. First Level (Soum) Hospital (left); Suturing of lacerated tongue by natural light (right). (Reproduced with permission from Intermountain Healthcare. Photo contributor: Raymond R. Price, MD.)BayankhongorKhentiiBayan-UlgiiBulganTuvDundgobiKhovdAltaiUvurkhangaiDornodDarkhanUulSukhbaatarOrkhonGobi-Sumber187 Soum doctors from 14 Aimags (Soum doctors = Doctor of health care centers)657 Surgeons and anesthesia doctors from aimag and city hospitals 29 Midwife and feldshers from rural provinces50 Nurses from rural provincesFigure 49-16. EESC Project: Mongolia 2004–2010. (Reproduced with permission from Henry JA, Orgoi S, Govind S, et al: Strengthening surgical services at the soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia, World J Surg. 2012 Oct;36(10):2359-2370.)access to training for EESC. Adopting a health systems strengthening approach to rectify these glaring deficiencies, Mongolia implemented a nationwide EESC program


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Surgery_Schwartz. J Surg. 2012 Oct;36(10):2359-2370.)access to training for EESC. Adopting a health systems strengthening approach to rectify these glaring deficiencies, Mongolia implemented a nationwide EESC program involving 14 of the 21 provinces (Aimags) from 2004 to 2010 (Fig. 49-16).96 In 6 years, dramatic improvements in short-term process measures were identified using the WHO Monitoring and Process form: 57.1% increase in availability of emergency rooms; 59.1% increase in the supply of emergency tool kits; and a 73.6% increase in the recording of emergency cases (Figs. 49-17 and 49-18).96 More importantly, countrywide morbidity and mortality dropped significantly (Fig. 49-19).97Violence and Injury Prevention. The Violence and Injury Prevention (VIP) program promotes numerous activities to assist countries to prevent and mitigate the consequences of violence and injury.98 While injury prevention is paramount, VIP provides guidance for strengthening trauma systems in countries of all economic


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Surgery_Schwartz. countries to prevent and mitigate the consequences of violence and injury.98 While injury prevention is paramount, VIP provides guidance for strengthening trauma systems in countries of all economic levels to improve emergency care and rehabilitation. VIP encourages development of systematic data collection and analysis to better guide appropriate interventions. Prevention programs include the WHO Helmet initiative, while the Essential Trauma Care Project (EsTC) creates standards for the care of injured patients and promotes systematic capacity building. VIP advocates support for the UN Decade of Action for Road Safety 2011–2020 and initiatives to achieve SDG 3.6, Brunicardi_Ch49_p2077-p2112.indd 209013/02/19 5:54 PM 2091GLOBAL SURGERYCHAPTER 49halving the number of global deaths and injuries from road traf-fic accidents by 2020, and SDG 11.2, which aims to provide access to safe, affordable, accessible, and sustainable transport systems for all by 2030.99WHO Safe Surgery Saves


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Surgery_Schwartz. injuries from road traf-fic accidents by 2020, and SDG 11.2, which aims to provide access to safe, affordable, accessible, and sustainable transport systems for all by 2030.99WHO Safe Surgery Saves Lives Initiative. Surgeons have always sought ways to prevent perioperative complications. Aseptic technique, one of the greatest forms of prevention in surgical care, requires vigilant reinforcement to prevent serious wound infections. In resource-limited areas inad-equate perioperative monitoring, lack of critical medications, and poor documentation place patients at increased risk for serious complications. The WHO Safe Surgery Saves Lives Initiative is a worldwide attempt to prevent perioperative complications.100Deaths from surgery occur at 0.4% to 0.8% globally; however, they may exceed 5% to 10% in developing countries. There are about 1 million deaths and 7 million disabling com-plications related to surgery worldwide, 50% of which are estimated to be preventable. The WHO Safe


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Surgery_Schwartz. 5% to 10% in developing countries. There are about 1 million deaths and 7 million disabling com-plications related to surgery worldwide, 50% of which are estimated to be preventable. The WHO Safe Surgery Saves Lives initiative targets preventable surgical injuries.100 The initiative identified 10 basic and essential objectives that can help prevent perioperative injuries (Table 49-5).101 A simple, three-stage checklist (initiated as the patient enters the operat-ing room, just before the procedure, and just prior to the patient leaving the room) implemented in eight high-, middle-, and low-income countries found a 50% reduction in the failure to meet basic safety standards resulting in a 50% decrease in mor-tality (Fig. 49-20).102Global Surgery and Public HealthSurgical care is increasingly recognized as an integral compo-nent of public health. Traditional teaching portrays sur-gery as the antithesis of public health: treating the individual instead of the community, reactionary


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Surgery_Schwartz. recognized as an integral compo-nent of public health. Traditional teaching portrays sur-gery as the antithesis of public health: treating the individual instead of the community, reactionary instead of pre-ventative, and too expensive especially for countries with devel-oping economies. Yet in reality, surgery and public health share many priorities and would benefit from greater integration in many areas (Fig. 49-21). For example, providing access to obstetrical care or birth attendants for every delivery could 10BeforeAfter0102030405060Wound debridementWound suturing, dressing, suture removalIncision and drainage of abscessesResuscitationFracture managementPenetrating injuriesBlunt injuriesAmputationBurns managementSkin graftingContracture releaseChest tube insertionCricothyroidotomy/TracheostomyRemoval of foreign bodyVenous peripheral cutdownUterine rupture/ectopic pregnancySuprapubic puncture/cystostomyLocal anaesthestic inÿltrationFigure 49-17. Surgical procedures performed 1 to


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Surgery_Schwartz. of foreign bodyVenous peripheral cutdownUterine rupture/ectopic pregnancySuprapubic puncture/cystostomyLocal anaesthestic inÿltrationFigure 49-17. Surgical procedures performed 1 to 2 years post training (13 Soum hospitals evaluated). (Reproduced with permission from Henry JA, Orgoi S, Govind S, et al: Strengthening surgical services at the soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia, World J Surg. 2012 Oct;36(10):2359-2370.)Brunicardi_Ch49_p2077-p2112.indd 209113/02/19 5:54 PM 2092SPECIFIC CONSIDERATIONSPART IIprevent the majority of vesicovaginal fistulas and markedly decrease the most common cause of maternal death—hemorrhage—for entire communities. Ninety percent of mortal-ity from injury occurs in LMICs, providing another area for surgical teams to lead preventative, population-based strategies to improve public health.103 Male circumcision is another exam-ple of a well-documented preventative, minor surgical


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Surgery_Schwartz. another area for surgical teams to lead preventative, population-based strategies to improve public health.103 Male circumcision is another exam-ple of a well-documented preventative, minor surgical proce-dure, capable of reducing the transmission of HIV.104,1050102030405060708090Establishmentof emergencyroomSupply ofemergency kitsRecording ofemergencycare casesInstructions onfacility andinstrumentusageBeforeAfterFigure 49-18. Pilot Soum hospitals’ evaluation 2 years post training. (Reproduced with permission from Henry JA, Orgoi S, Govind S, et al: Strengthening surgical services at the soum (first-referral) hospital: the WHO emergency and essential surgical care (EESC) program in Mongolia, World J Surg. 2012 Oct;36(10):2359-2370.).60.50.40.30.20.10.00200120022003200420052006200720082009Percentage of deathsPercentage of complicationsFigure 49-19. Surgical morbidity and mortality: Mongolia 2001–2009. (Reproduced with permission from Intermountain


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Surgery_Schwartz. of deathsPercentage of complicationsFigure 49-19. Surgical morbidity and mortality: Mongolia 2001–2009. (Reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 209213/02/19 5:54 PM 2093GLOBAL SURGERYCHAPTER 49devotes an entire volume to essential surgery, emphasizing its importance as a key part of health worldwide.7 There are three significant developments helping to accelerate the integration of surgery and public health:1. Improved understanding of the burden of surgical disease and its significant component of the overall burden of global disease2. Recognition that surgery has a primary, secondary, and ter-tiary preventative role (Table 49-6)3. Documentation that surgical care can be cost-effective for community-based healthcareTable 49-5Ten basic and essential objectives for safe surgery (WHO*)1. Operate on the correct patient at the correct site2. Use method known to prevent harm from anesthetic administration, while protecting the patient


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Surgery_Schwartz. and essential objectives for safe surgery (WHO*)1. Operate on the correct patient at the correct site2. Use method known to prevent harm from anesthetic administration, while protecting the patient from pain3. Recognize and effectively prepare for life-threatening loss of airway or respiratory function4. Recognize and effectively prepare for risk of high blood loss5. Avoid inducing any allergic or adverse drug reaction known to be a significant risk for the patient6. Consistently use method known to minimize risk of surgical site infection7. Prevent inadvertent retention of instruments or sponges in surgical wounds8. Secure and accurately identify all surgical specimens9. Effectively communicate and exchange critical patient information for the safe conduct of the operation10. Establish routine surveillance of surgical capacity, volume, and results*WHO: World Health Organization.Data from WHO Guidelines for Safe Surgery


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Surgery_Schwartz. information for the safe conduct of the operation10. Establish routine surveillance of surgical capacity, volume, and results*WHO: World Health Organization.Data from WHO Guidelines for Safe Surgery 2009.PreventiondiagnosistreatmentrehabilitationSurgeryPublichealthFigure 49-21. Overlapping priorities of surgery and public health. (Reproduced with permission from Intermountain Healthcare.)Even after Learmonth presented his landmark lecture in 1949 “The Contributions of Surgery to Preventive Medicine” at the University of London’s Heath Clark Lecture series, surgery has been neglected as a component of public health.106,107 DCP3 Before induction of anaesthesia Before skin incisionBefore patient leaves operating roomSurgical safety checklist(with at least nurse and anaesthetist)(with nurse, anaesthetist and surgeon)(with nurse, anaesthetist and surgeon)This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.Nurse verbally


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Surgery_Schwartz. anaesthetist and surgeon)(with nurse, anaesthetist and surgeon)This checklist is not intended to be comprehensive. Additions and modifications to fit local practice are encouraged.Nurse verbally confirms: The name of the procedure Completion of instrument, sponge and needle counts Specimen labeling (read specimen labels aloud, including patient name) Whether there are any equipment problems to be addressedTo surgeon, anaesthetist and nurse: What are the key concerns for recovery and management of this patient?Based on the WHO Surgical Safety Checklisthttp://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf© World Health Organization 2009 All rights reservedHas the patient confirmed his/her identity,site, procedure, and consent? YesIs the site marked? Yes Not applicableIs the anaesthesia machine and medicationcheck complete? YesIs the pulse oximeter on the patient andfunctioning? YesDoes the patient have a:Known allergy? No YesDifficult airway or aspiration risk? No


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Surgery_Schwartz. the anaesthesia machine and medicationcheck complete? YesIs the pulse oximeter on the patient andfunctioning? YesDoes the patient have a:Known allergy? No YesDifficult airway or aspiration risk? No Yes, and equipment/assistance availableRisk of >500 ml blood loss (7 ml/kg in children)? No Yes, and two IVs/central access and fluids planned Confirm all team members have introduced themselves by name and role. Confirm the patient’s name, procedure, and where the incision will be made.Has antibiotic prophylaxis been given within the last 60 minutes? Yes Not applicableAnticipated critical eventsto Surgeon: What are the critical or non-routine steps? How long will the case take? What is the anticipated blood loss?To anaesthetist: Are there any patient-specific concerns?To nursing team: Has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns?Is essential imaging displayed? Yes Not applicableFigure 49-20. Surgical safety checklist. (Reproduced


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Surgery_Schwartz. (including indicator results) been confirmed? Are there equipment issues or any concerns?Is essential imaging displayed? Yes Not applicableFigure 49-20. Surgical safety checklist. (Reproduced with permission from WHO surgical safety checklist, 2009, http://whqlibdoc.who.int/publications/2009/9789241598590_eng_Checklist.pdf. © World Health Organization 2009 All rights reserved.)Brunicardi_Ch49_p2077-p2112.indd 209313/02/19 5:54 PM 2094SPECIFIC CONSIDERATIONSPART IIStrategies for Integration of Global Surgery and Public Health. Three areas stand out as opportunities for integration of global surgery and public health: education, professional societies, and multinational health policy organizations. From an education standpoint, several universities in HICs have developed formal programs for the study of surgery and public health.108,109Diseases commonly present in very late stages in LMICs and in disadvantaged populations in developed countries. Many morbid conditions could have


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Surgery_Schwartz. for the study of surgery and public health.108,109Diseases commonly present in very late stages in LMICs and in disadvantaged populations in developed countries. Many morbid conditions could have been cured while localized in their earlier stages and likely eradicated by a local surgical pro-cedure. Early recognition and treatment of surgically correctable diseases is a critical preventive role for surgery. Many surgical procedures are not only a form of tertiary prevention, but are also forms of primary prevention (Table 49-7).110Assigning Disease Priorities. Global surgery interventions can be prioritized to identify those conditions in which clini-cians and public health professionals should collaborate most closely—targeting those diseases that impose the largest bur-den on a society and have a highly successful surgical outcome (Table 49-8).94,111 There are four broad, high-priority areas where surgery has an important role for public health interventions: trauma care;


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Surgery_Schwartz. a society and have a highly successful surgical outcome (Table 49-8).94,111 There are four broad, high-priority areas where surgery has an important role for public health interventions: trauma care; obstetrical emergencies; acute-surgical emergen-cies; and nonacute surgical conditions that significantly affect the quality of life (Table 49-9).10Trauma Care. The Essential Trauma Care Project (EsTC) begun in 2001 is a collaboration effort between the International Association for Trauma Surgery and Intensive Care, an inte-grated society within the International Society of Surgery-Societe-Internationale Chirurgie (ISS-SIC) and the World Health Organization (WHO), specifically the Violence and Injury Prevention unit. The project culminated in a document that identified 11 core essential trauma care services (“the rights of the injured patient”) that ought to be available at all levels of healthcare facilities (Table 49-10).112 In addition, the docu-ment delineated 260 human and physical


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Surgery_Schwartz. care services (“the rights of the injured patient”) that ought to be available at all levels of healthcare facilities (Table 49-10).112 In addition, the docu-ment delineated 260 human and physical resources that should be available based on the type of facility (Table 49-11).Table 49-6Prevention strategiesPREVENTION STRATEGYTARGETGOAL1. PrimaryRoot causes of diseaseEliminate or reduce risk of developing illness2. SecondaryIllness or disease at earliest stagesLimit progression of disease3. TertiaryDisease at later stagesCure or limit the effect of existing diseaseData from deVries C, RR Price: Global Surgery and Public Health: A New Paradigm, 1st ed. Sudbury, MA: Jones & Bartlett Learning, LLC; 2012.Table 49-7The role of surgery for primary prevention of cancerTERTIARY SURGICAL PROCEDUREPRIMARY CANCER PREVENTEDBreast lumpectomy for ductal carcinoma in situBreastColonoscopic polypectomyColonColposcopy and excisionCervicalResection of actinic keratosisSkinResection of leukoplakia and


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Surgery_Schwartz. CANCER PREVENTEDBreast lumpectomy for ductal carcinoma in situBreastColonoscopic polypectomyColonColposcopy and excisionCervicalResection of actinic keratosisSkinResection of leukoplakia and erythroplakiaOralData from Riviello R, Meara JG, Rogers SO. Comemntary: Cancer Care and Control–the role of surgery. Global Surgery and Anesthesia, 2010. http://www.ghdonline.org/surgery/discussion/cancer-care-and-control-the-role-of-surgery/.Table 49-8Prioritization of surgical conditionsPRIORITY*PUBLIC HEALTH BURDENSURGICAL PROCEDURE SUCCESSFULCOST-EFFECTIVE AND FEASIBLE TO PROMOTE GLOBALLY1HighHighlyHighly2ModerateModeratelyModerately3LowNeither highly or moderatelyLow*Priority one implies that all three conditions must be met. The priority should be shifted to 2 or 3 if any of the conditions are moderate or low.Data from Mock C, Cherian M, Juillard C, et al: Developing priorities for addressing surgical conditions globally: furthering the link between surgery and public health policy, World J


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Surgery_Schwartz. or low.Data from Mock C, Cherian M, Juillard C, et al: Developing priorities for addressing surgical conditions globally: furthering the link between surgery and public health policy, World J Surg. 2010 Mar;34(3):381-385.Table 49-9The role of surgery for public health strategiesTrauma carePrevention of death and chronic disability by the provision of timely, expert, and complete surgical careObstetrical emergenciesTimely surgical intervention in obstructed labor, in preand post-partum hemorrhage, and other obstetrical complicationsAcute surgical emergenciesProvision of competent surgery to treat a wide range of emergency abdominal and nonabdominal conditionsNonacute surgical conditionsSurgical care for several elective conditions that have a significant effect on the quality of life such as cataract, otitis media, clubfoot, and herniasData from Jamison DT, Breman JG, Measham AR et al: Disease Control Priorities in Developing Countries, 2nd ed. New York, NY: Oxford University Press for


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Surgery_Schwartz. cataract, otitis media, clubfoot, and herniasData from Jamison DT, Breman JG, Measham AR et al: Disease Control Priorities in Developing Countries, 2nd ed. New York, NY: Oxford University Press for the World Bank; 2006.Brunicardi_Ch49_p2077-p2112.indd 209413/02/19 5:54 PM 2095GLOBAL SURGERYCHAPTER 49The EsTC recommendations provide a cost-effective framework for LMICs to improve their trauma care. These recommendations have been used as a planning guide and as an advocacy statement. To catalyze strengthening trauma and emergency care in lowand middle-income countries, in 2007, the WHA adopted a resolution on emergency care systems (resolution WHA 60.22).113,114 This first-ever WHA resolution dedicated specifically to trauma care highlights the importance accorded by world governments in caring for their injured.Quality improvement programs provide inexpensive tools to strengthen trauma systems. National trauma registries, integral for trauma research, can be used to monitor and


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Surgery_Schwartz. in caring for their injured.Quality improvement programs provide inexpensive tools to strengthen trauma systems. National trauma registries, integral for trauma research, can be used to monitor and improve patient outcomes.115,116 Yet very few trauma regis-tries exist in LMICs.117,118 The World Bank stated, “It is criti-cal for LMICs to create or strengthen existing trauma systems to improve outcomes.”119,120 Trauma systems exist in varying states of development in different countries, and even within countries. Initiatives to strengthen trauma systems target the full spectrum of services: prevention, prehospital and defini-tive hospital care, rehabilitation, and process improvement and patient safety initiatives. Nearly 2 million lives could be saved each year if LMICs could design and implement simple trauma care initiatives that reduced the case fatality rates among seri-ously injured patients to equal those in HICs (Fig. 49-22).119,120 In one Canadian province, introducing simple


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Surgery_Schwartz. simple trauma care initiatives that reduced the case fatality rates among seri-ously injured patients to equal those in HICs (Fig. 49-22).119,120 In one Canadian province, introducing simple prehospital Table 49-10Essential trauma care services1. Obstructed airway appropriately maintained2. Impaired breathing supported3. Pneumothorax and hemothorax promptly diagnosed and treated4. Bleeding promptly stopped (internal or external)5. Shock recognized and treated appropriately (I.V. fluids)6. Timely decompression of space occupying lesions to prevent secondary brain injury7. Abdominal injuries diagnosed and promptly repaired (intestinal injuries and others)8. Disabling extremity injuries corrected9. Potentially unstable spine injuries identified and managed (early immobilization)10. Minimize consequences of injuries by appropriate rehabilitative services11. Medication to provide above services and relieve pain readily availableData from Mock C, Joshipura M, Goosen J, et al: Overview of


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Surgery_Schwartz. consequences of injuries by appropriate rehabilitative services11. Medication to provide above services and relieve pain readily availableData from Mock C, Joshipura M, Goosen J, et al: Overview of the Essential Trauma Care Project, World J Surg. 2006 Jun;30(6):919-929.Table 49-11Airway management recommendations for physical and human resources based on type of facility (sample from EsTC*) FACILITY LEVELKNOWLEDGE AND SKILLSBASICGENERAL PRACTITIONERSPECIALISTTERTIARYAssessment of airway compromiseEEEEManual maneuvers (chin lift, jaw thrust)EEEEInsertion of oral or nasal airwayDEEEEndotracheal IntubationDDEEEquipment and supplies Oral or nasal airwayDEEELaryngoscopeDDEEEndotracheal tubeDDEECapnographyIDDDE: essential; D: desirable; I: irrelevant (not usually to be considered as the level in question).*EsTC: Essential Trauma Care.Data from Mock C, Lromand JD, Goosen J, et al: Guidelines for essential trauma care. Geneva: World Health Organization; 2004.Kumasi,Ghana0LowMiddleCountry


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Surgery_Schwartz. in question).*EsTC: Essential Trauma Care.Data from Mock C, Lromand JD, Goosen J, et al: Guidelines for essential trauma care. Geneva: World Health Organization; 2004.Kumasi,Ghana0LowMiddleCountry incomeHigh20406080Fatalities (percent)(ISS ˜9)Monterrey,MexicoSeattle,WashingtonUnited StatesFigure 49-22. Case fatality rates for severely injured people, 1998. Note: ISS = injury severity score. Income classifications are based on status at the time of the study. Ghana is now a lower-middle income country, and Mexico is an upper-middle-income country. (Reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 209513/02/19 5:54 PM 2096SPECIFIC CONSIDERATIONSPART IIinterventions and improving the focus on trauma at the policy level demonstrated consistent improvement in trauma-related morbidity and mortality, over a relatively short time period (Fig. 49-23).121Obstetrical and Other Acute Surgical Emergencies. Reduction of maternal deaths and long-term


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Surgery_Schwartz. in trauma-related morbidity and mortality, over a relatively short time period (Fig. 49-23).121Obstetrical and Other Acute Surgical Emergencies. Reduction of maternal deaths and long-term disability are high priorities for the international community.122 Despite the 44% reduction in maternal deaths from 1990 to 2015, approxi-mately 830 women—mostly in LMICs—still die daily from preventable causes related to pregnancy and childbirth.123 For every maternal death, 30 women are incapacitated by chronic problems that reduce their quality of life and ability to care for their families. High priority surgical procedures to improve maternal health include cesarean section, hysterectomy for postpartum bleeding and uterine rupture, management of ectopic pregnancy, and dilatation and curettage.111 In 2015, the LCGS reported that maternal mortality was closely related to density of surgical, anesthetic, and obstetrical providers (SAOPs). They showed that maternal mortality throughout the world


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Surgery_Schwartz. In 2015, the LCGS reported that maternal mortality was closely related to density of surgical, anesthetic, and obstetrical providers (SAOPs). They showed that maternal mortality throughout the world appeared to decrease—by 13.1% on average—for every 10 unit increase in SAOPs per 100,000 persons, a strong argument for addressing maldistribution of providers related to surgical disease.16In terms of nonobstetrical acute surgical emergencies, about 90% could be addressed by developing the capability to care for the 10 most common acute surgical conditions in any local region. While a few types of disease processes vary by geo-graphical location, there are many that are universal, including appendicitis, strangulated hernia, small bowel obstruction, per-forated peptic ulcer, fractures, lacerations, and wounds.Nonacute Surgical Conditions. Even common nonacute conditions can have significant impact on the quality of life. Hernias can prevent otherwise healthy individuals from work-ing,


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Surgery_Schwartz. and wounds.Nonacute Surgical Conditions. Even common nonacute conditions can have significant impact on the quality of life. Hernias can prevent otherwise healthy individuals from work-ing, especially in societies where the economy relies heavily on manual labor. Cleft lip and cleft palate deformities interfere with the ability to speak or eat properly and predispose affected indi-viduals to chronic ear infections leading to hearing loss. Many live in isolation because social ostracism prevents them from attending school, marrying, or holding jobs.124 Plastic surgeons who pioneered global outreach for reconstructive procedures for cleft lip and palate opened the door for subsequent outreach by other specialties, including ophthalmology, orthopedics, general surgery, urology, and dentistry.125-127The most common form of blindness is caused by cata-racts. Cataracts decrease the quality of life and the socioeco-nomic status for both the blind person and his or her family. The fact that


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Surgery_Schwartz. most common form of blindness is caused by cata-racts. Cataracts decrease the quality of life and the socioeco-nomic status for both the blind person and his or her family. The fact that 90% of blind people no longer work reveals the extra burdens carried by the family members who care for them.128 The Himalayan Cataract Project (HCP) is a highly successful initiative focusing on cataracts in Asia and Africa. HCP pri-orities and measurable outcomes illustrate how combining key public health concepts with a comprehensive approach to sur-gical care creates a model for curing disease, building econo-mies, and delivering hope in resource-poor areas9 (Box: The Himalayan Cataract Project: A Sustainable Public Health Approach for Curing Blindness).1992–930%10%20%30%Trauma mortality40%50%60%1993–941994–951995–961996–971997–981998–991999–002000–012001–021990: Government ofQuebec deÿnes traumacare as a priority1993: Four Quebechospitals designatedlevel 1 trauma centers1993: Introduction


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Surgery_Schwartz. Government ofQuebec deÿnes traumacare as a priority1993: Four Quebechospitals designatedlevel 1 trauma centers1993: Introduction ofguidelines aimed atreducing prehospital times1995: Implementation oftriage and transfer protocolsbased on injury severity1995: Designation oflevel II and III centers1996–97: Specializedtrauma centersdesignated2002: Eliminationof MDs fromprehospital care1994–95: Traumabecomes a priority inlevel 1 centers2000: Guidelines todecrease MD dispatch toprehospital traumaFigure 49-23. Improvement in mortality among severely injured patients in Canada through evolving interventions. Note: Inclusion criteria specified death as a result of injury or an injury severity score (ISS) exceeding 12, a prehospital index exceeding 3, two or more injuries with an abbreviated injury scale score of 3 or higher, or a hospital stay exceeding 3 days. (Adapted with permission from Liberman M, Mulder D, Lavoie A et al. Implementation of a Trauma Care System: Evolution through


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Surgery_Schwartz. injury scale score of 3 or higher, or a hospital stay exceeding 3 days. (Adapted with permission from Liberman M, Mulder D, Lavoie A et al. Implementation of a Trauma Care System: Evolution through Evaluation, J Trauma. 2004 Jun;56(6):1330-1335.)Brunicardi_Ch49_p2077-p2112.indd 209613/02/19 5:54 PM 2097GLOBAL SURGERYCHAPTER 49The Himalayan Cataract Project (HCP): A Sustainable Public Health Approach for Curing BlindnessAccording to the WHO criteria, 285 million people worldwide are visually disabled. Of that population, 39 million are classified as bilaterally blind; 90% live in the developing world where poor water quality, lack of sanitation, malnutrition, and inadequate services cause a higher incidence of eye disease.128 The most common cause of avoidable blindness in LMICs is cataract (43%). Nepal has one of the highest incidences of cataracts partially due to increased exposure to ultraviolet sunlight encountered at its higher elevations; 62% of total blindness in Nepal is


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Surgery_Schwartz. (43%). Nepal has one of the highest incidences of cataracts partially due to increased exposure to ultraviolet sunlight encountered at its higher elevations; 62% of total blindness in Nepal is due to cataracts.129In 1995, Sanduk Ruit joined forces with Geoffrey Tabin to establish the Himalayan Cataract Project (HCP). In the early 1990s, difficult geography with inadequate transportation, the high cost of intraocular lenses, and a lack of trained ophthalmologists, assistants, and nurses limited access to cataract surgery for the poor.HCP developed and defined six priorities, each with an associated public health principle and outcome measurement that provided the basis for assessing success and for implementing change (Fig. 49-24). HCP’s care model targeted the entire population of blind people with cataracts regardless of the ability to pay. Since most of the potential patients lived in remote areas, HCP found it imperative to take cataract surgery to the local communities. The


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Surgery_Schwartz. people with cataracts regardless of the ability to pay. Since most of the potential patients lived in remote areas, HCP found it imperative to take cataract surgery to the local communities. The Tilganga Institute of Ophthalmology (TIO) in Katmandu, Nepal, has served as a base from which 493 doctors and over 19,000 ophthalmic personnel of all levels have received training since 1994. Through the TIO and its outreach programs, over 4,657,748 people have been screened, and more than 307,611 eye surgeries have been performed since 1994 (Fig. 49-25).130The TIO developed an ophthalmology residency training program implementing standards set forth by the American Academy of Ophthalmology. In addition to the formal residency program for ophthalmologists, HCP established training programs for community eye care workers in a three-year Ophthalmic Assistant Training Program.Ruit developed an innovative sutureless technique for cataract surgery yielding equivalent results to those in developed


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Surgery_Schwartz. eye care workers in a three-year Ophthalmic Assistant Training Program.Ruit developed an innovative sutureless technique for cataract surgery yielding equivalent results to those in developed countries but also reproducible in resource-constrained areas. By redesigning the intraocular lens implant and mass producing it locally in Nepal for U.S. $4, Ruit and Tabin provided a low-cost alternative to the higher-priced lens produced in developed countries. A local business—the Fred Hollows Intraocular Lens Factory—mass produces the lenses and supports the local economy by creating a new sustainable business.131HCP also designed a compassion-driven, culturally acceptable method for cost-recovery that involves a sliding scale for payment: 45% of patients pay U.S. $120; 20% pay a smaller amount based on their economic situation; and 35% receive cataract surgery for free.With the rapidity and scale of success experienced in Nepal, HCP and TIO began expanding their efforts globally. HCP is now


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Surgery_Schwartz. on their economic situation; and 35% receive cataract surgery for free.With the rapidity and scale of success experienced in Nepal, HCP and TIO began expanding their efforts globally. HCP is now actively working to replicate and proliferate their model in countries throughout South Asia and Africa by developing high-quality eye care systems, supporting local institutions, and training local doctors and ophthalmic personnel. Since 2005, HCP has trained over 300 ophthalmic personnel from 19 countries.HCPprioritiesPublic healthprinciplesImplementationAccessibleAppropriateDisruptive technologySustainable growthAffordableSustainabilityHumanitarianHigh qualityInnovationDirect impactAffordabilityReplicationEntire populationCare at local levelCare comparable to western standardsDisease with high incidence/prevalenceDesigned $4 lensLocal businessSkills transferBuilding infrastructureDelivery model$20 cost/cataractMeet needs of current populationCulturally and economically acceptableFigure


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Surgery_Schwartz. incidence/prevalenceDesigned $4 lensLocal businessSkills transferBuilding infrastructureDelivery model$20 cost/cataractMeet needs of current populationCulturally and economically acceptableFigure 49-24. Himalayan cataract project priorities, public health principles, and outcome measurements. (Redrawn from Himalayan Cataract Project and Tilganga Eye Center, Cureblindness.org, 129-131, by permission. Illustration reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 209713/02/19 5:54 PM 2098SPECIFIC CONSIDERATIONSPART IICancer InitiativesSurgery for cancer in public health plays a role not only for curative surgery, but also for early diagnosis, prevention, and palliation.52,110,132,133 Solid tumors, in their early stages, presents insidiously as a nonacute surgical problem. Due to cancer’s recent recognition as a leading cause of death, cancer has been identified as a health priority in LMICs. Most solid tumors are incurable without surgery and


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Surgery_Schwartz. surgical problem. Due to cancer’s recent recognition as a leading cause of death, cancer has been identified as a health priority in LMICs. Most solid tumors are incurable without surgery and at a minimum require surgical excision of the primary lesion.110It is often not appreciated that surgeons provide a signif-icant amount of primary care and are the principle providers involved in endoscopic screening and treatment of gastrointes-tinal tumors in LMICs. In countries without specialized ser-vices, low-cost and effective treatment options combining early prevention and treatment with off-patent drug use have led to coverage of cancer treatment in several middle-income coun-tries’ national health insurance plans.52 Cancer care provides significant opportunity for including surgery in community-wide public health programs as a high priority according to the prioritization model (see Table 49-6); cancer has a high public health burden, is treated with highly successful procedures, and


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Surgery_Schwartz. public health programs as a high priority according to the prioritization model (see Table 49-6); cancer has a high public health burden, is treated with highly successful procedures, and can be cost-effective and feasible globally. In 2009, a coalition of leaders in cancer care and public health organized the Global Task Force on Expanded Access to Cancer Care and Control in Developing Countries (GTFCCC).134 GTFCCC’s mission is to expand access to cancer prevention, detection, and care in LMICs. Successful partnerships have already been entered into Haiti, Rwanda, Mexico, Malawi, and Jordan.Cost-Effectiveness of Surgical Care. Funders in healthcare look for measurable return on their investments. While compari-son of outcomes and objective measures would be ideal, reality demonstrates that healthcare budgets more commonly are dic-tated by politics rather than actual need. Nevertheless, in a world of limited resources and tightening budgets for healthcare, cost-effective analyses of


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Surgery_Schwartz. healthcare budgets more commonly are dic-tated by politics rather than actual need. Nevertheless, in a world of limited resources and tightening budgets for healthcare, cost-effective analyses of various options for intervention are critical for policy makers. Comparing various options that have differ-ent outcomes is an approach called cost-utility analysis (CUA). Surgical interventions can be evaluated by specific diseases or conditions, or by systems or services required to support the delivery of surgical care. In 1990, the World Bank defined the Disability Adjusted Life Year (DALY) as the sum of Years of Life Lost (YLL) due to premature mortality in the population and the Years Lost due to Disability (YLD) for people living with the health condition or its consequences (DALY = YLL + YLD). Evaluating the cost per DALY averted is one approach for comparing the cost-utility between medical and surgical interventions. Recent surgical cost/DALY studies identifying the


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Surgery_Schwartz. (DALY = YLL + YLD). Evaluating the cost per DALY averted is one approach for comparing the cost-utility between medical and surgical interventions. Recent surgical cost/DALY studies identifying the cost-effectiveness of various types of surgical care have allowed surgical initiatives to be considered when prioritizing public health initiatives.The World Bank arbitrarily defined U.S. $100 per DALY averted per day in low-income countries as highly cost-effective. Compared to other public health initiatives, developing basic and emergency surgical care at the district level hospital is as cost-effective as, or more so, than typical public health programs such as retroviral treatments for HIV/AIDS or immunization for measles (Fig. 49-26).135-139Using the WHO’s cost-effectiveness standards, investing in emergency obstetrical systems, including timely caesarean delivery, can also be considered “highly cost-effective” for 48 of 49 countries in which there are currently inadequate numbers of


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Surgery_Schwartz. in emergency obstetrical systems, including timely caesarean delivery, can also be considered “highly cost-effective” for 48 of 49 countries in which there are currently inadequate numbers of cesarean deliveries.140,141 The median cost per DALY averted by cesarean-section was $304. In addition, the cost-benefit ratio in 46 of 49 countries was >1, suggesting that investment in cae-sarean delivery is a viable economic proposition.Inguinal hernia repair is one of the most common opera-tions performed worldwide. Tension-free inguinal hernia repairs performed with mosquito netting or polypropylene mesh were cost-effective in Western Ecuador and Western Ghana ($78.18 per DALY and $12.88 per DALY averted, respectively).136,142 Using mosquito netting in India was 3700 times cheaper than using traditional polypropylene mesh.143Using “value of lost output” (VLO) data representing 90% of the world’s population, it is estimated that U.S. $20.7 trillion would be lost between 2015 and 2030 due to


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Surgery_Schwartz. polypropylene mesh.143Using “value of lost output” (VLO) data representing 90% of the world’s population, it is estimated that U.S. $20.7 trillion would be lost between 2015 and 2030 due to unmet surgical needs and their inherent morbidity and mortality.144 Projected 1119941996199820002002200420062008201020122014201635,00030,00025,00020,00015,00010,00050000SurgeriesYearFigure 49-25. Eye surgeries at Tilganga Eye Center and outreach. Note: 2015 was the year of a devastating earthquake in Nepal. (Redrawn from Himalayan Cataract Project and Tilganga Eye Center, Cureblindness.org, 129-131, by permission. Illustration reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 209813/02/19 5:54 PM 2099GLOBAL SURGERYCHAPTER 49economic losses of such magnitude have underlined the impor-tance of prioritizing surgical infrastructure and the cost-effective nature of many interventions within the surgical realm.Factors Affecting Utilization and Outcome for


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Surgery_Schwartz. have underlined the impor-tance of prioritizing surgical infrastructure and the cost-effective nature of many interventions within the surgical realm.Factors Affecting Utilization and Outcome for Surgical Care. There are three major factors that severely limit utiliza-tion of surgical services:1. Socioeconomic and cultural factors2. Accessibility of facilities3. Quality of care (Fig. 49-27)145The decision to seek timely care is affected by the costs associated with time off from work and inability to support the family during the absence, transportation and lodging, and the surgical services themselves. Cultural and religious tradi-tions may define acceptability of various treatment options. For example, many people in Mongolia refuse to have surgery on Tuesdays as this is viewed as a “bad luck” day. Understanding local customs and cultural concerns can improve utilization of surgical services.At the intersection of cost and culture are “willingness to pay” (WTP) models, which predict


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Surgery_Schwartz. luck” day. Understanding local customs and cultural concerns can improve utilization of surgical services.At the intersection of cost and culture are “willingness to pay” (WTP) models, which predict how a society’s perceived costs of obtaining care versus tolerating a medical condition will lead to or prevent them from seeking care. Such calcula-tions can inform which policies are most likely to yield improved health for a country or region, and they rely heavily on per capita gross domestic product (GDP) and DALYs averted. It is vital to understand that these models, and the policies they inform, are context-dependent. What is perceived as socially valuable in Tanzania may be seen as overpriced or unnecessary in Haiti. As global surgical advocates work with public health experts to strengthen surgical systems, it will be important to remember that context, culture, and cost are indivisible from one another.146Austere environments, difficult terrain, and long distances from health


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Surgery_Schwartz. surgical systems, it will be important to remember that context, culture, and cost are indivisible from one another.146Austere environments, difficult terrain, and long distances from health care facilities significantly delay or prevent access to surgical care. Triage and transfer guidelines along with tele-medicine have the potential to mitigate the limitations of geog-raphy. However, without adequately trained care providers and support staff, the risk for poor outcomes is increased.Recognizing these three important factors for increasing utilization and outcomes, Mongolia initiated a public health approach for the management of gallbladder disease incorpo-rating minimally invasive surgery (Box: The Public Health Approach to Management of Gallbladder Disease in Mongolia).Figure 49-26. Cost-effectiveness of surgical interven-tions, compared to two key medical interventions. Note: DALY = disability-adjusted life year. (Reproduced with permission from Intermountain


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Surgery_Schwartz. 49-26. Cost-effectiveness of surgical interven-tions, compared to two key medical interventions. Note: DALY = disability-adjusted life year. (Reproduced with permission from Intermountain Healthcare.)Orthopedic surgery tripTrauma centerCesarean deliveryHydrocephalus repairTrachoma surgeryCleft lip and palate repairHernia repairSurgical hospitalCataract surgeryObstetric hospitalMeasles vaccinationAntiviral therapy for HIV$1/DALY$10/DALY$100/DALY$1000/DALYRange Cost/DALY (2012 US$)Figure 49-27. Factors affecting utilization and outcome of surgical care. (Adapted with permission from UNFPA United Nations Population Fund (UNFPA); Setting stan-dards for emergency obstetric and new-born care; Available from: https://www.unfpa.org/resources/setting-standardsemergency-obstetric-and-newborn-care. Illustration reproduced with permission from Intermountain Healthcare.)Socioeconomic/cultural factorsAccessibility offacilitiesQuality ofcarePhase IDecision toseek carePhase IIIdentifying &


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Surgery_Schwartz. Illustration reproduced with permission from Intermountain Healthcare.)Socioeconomic/cultural factorsAccessibility offacilitiesQuality ofcarePhase IDecision toseek carePhase IIIdentifying & reachingmedical facilityPhase IIIReceipt of adequate &appropriate treatmentFactors affectingutilization & outcomePhases of delayBrunicardi_Ch49_p2077-p2112.indd 209913/02/19 5:54 PM 2100SPECIFIC CONSIDERATIONSPART IIThe Public Health Approach to Management of Gallbladder Disease in MongoliaMongolia, the most sparsely populated country in the world, covers a large geographic area nestled between China and Siberia.147 The austere environment with extremes of weather, dry deserts, and high mountains present significant obstacles for road building limiting transportation for patients in the vast rural areas (Fig. 49-28). Significant deficiencies in infrastructure, supplies, equipment, and human resources at primary healthcare facilities exist: sporadic electricity, no fully qualified surgeons or


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Surgery_Schwartz. areas (Fig. 49-28). Significant deficiencies in infrastructure, supplies, equipment, and human resources at primary healthcare facilities exist: sporadic electricity, no fully qualified surgeons or anesthesiologists, and less than half the facilities with running water.3 In 2006, Healthcare expenditures reached only U.S. $23.2 per capita.148,149The second most common cause of inpatient morbidity in Mongolia has transitioned to gastrointestinal diseases with liver disease, appendicitis, and gallbladder disease the top three causes.150 While laparoscopic cholecystectomy was introduced in Mongolia in 1994, by 2005 only 2% of gallbladders were removed laparoscopically, and then, only in the capital city.151 A cohort study in 2005 comparing open with laparoscopic cholecystectomy by Dr. Sergelen, the chief of surgery at the Health Sciences University of Mongolia (HSUM), found the wound infection rate to be significantly lower, hospital stays shorter, and hospital expenditures 50% less with


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Surgery_Schwartz. the chief of surgery at the Health Sciences University of Mongolia (HSUM), found the wound infection rate to be significantly lower, hospital stays shorter, and hospital expenditures 50% less with laparoscopy compared to open cholecystectomy.152Dr. Sergelen formulated a plan to expand access to laparoscopic surgery throughout Mongolia. This plan targeted the three main areas affecting utilization and outcome:1. Quality of Care:a. Develop a laparoscopic training didactic and practical course to train surgical teams and transfer skills safely.b. Improve the surgical infrastructure for each facility.c. Expand the surgical residency to include laparoscopic training.2. Accessibility of Quality Care:a. Begin training surgical teams in the capital city, but then expand them to four carefully selected regional diagnostic treatment and referral centers (RDTRCs) in all four quadrants of the country.b. Invite industry to offer cost-affordable supplies and replacement parts to sustain the


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Surgery_Schwartz. selected regional diagnostic treatment and referral centers (RDTRCs) in all four quadrants of the country.b. Invite industry to offer cost-affordable supplies and replacement parts to sustain the laparoscopic equipment in Mongolia.3. Socioeconomic/Cultural Factors:a. Educate the public on the increased benefits of laparoscopic surgery so they would initiate lobbying efforts demanding the government increase funding for these services.b. Educate government leaders about the need and benefit of laparoscopic cholecystectomy for the Mongolian people.The strategic initiative that began by expanding laparoscopic cholecystectomy within the capital city and then to the four key Regional Diagnostic and Treatment Referral Centers (RDTRCs) created the foundation for countrywide access to high-quality modern surgery for a regionally prevalent disease (Fig. 49-29).147,153In 2011, through a multinational partnership (HSUM, the Dr. WC Swanson Family Foundation (SFF), the Society of American


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Surgery_Schwartz. modern surgery for a regionally prevalent disease (Fig. 49-29).147,153In 2011, through a multinational partnership (HSUM, the Dr. WC Swanson Family Foundation (SFF), the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), and the University of Utah Department of Surgery), Mongolia experienced a Figure 49-28. Rural Ger. (Used with permission from Michelle K. Price.)Brunicardi_Ch49_p2077-p2112.indd 210013/02/19 5:54 PM 2101GLOBAL SURGERYCHAPTER 49dramatic transformation from open to laparoscopic cholecystectomy; laparoscopic replaced open cholecystectomy and became the primary method to remove the gallbladder in Mongolia (Fig. 49-30).154As people began to see their neighbors return to functional ability faster with the laparoscopic approach, the Mongolian people developed increased trust in their healthcare providers and the quality of care they could receive. The Ministry of Health committed increased funding for laparoscopic surgery and changed existing laws


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Surgery_Schwartz. increased trust in their healthcare providers and the quality of care they could receive. The Ministry of Health committed increased funding for laparoscopic surgery and changed existing laws making it easier for hospitals to purchase the needed equipment and supplies solidifying the needed financial and business models to support laparoscopic surgery in Mongolia.By 2016, with the introduction of laparoscopic training into the surgical residency program and development of laparoscopic fellowship training for surgical teams from outlying provinces, 17 of 21 provinces now provide laparoscopic cholecystectomy allowing patients the benefits of less pain, smaller incisions, fewer wound infections, and more rapid return to work (Fig. 49-31).KhovdChoybalsanUlaanbaatarErdenetArvaikheerMurunArvaikheer regionaldiagnostic and treatmentreferral centerHospital #1Hospital #2Cancer hospitalNomun hospitalMurungeneral hospitalErdenet regionaldiagnostic and treatmentreferral centerKhovd


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Surgery_Schwartz. regionaldiagnostic and treatmentreferral centerHospital #1Hospital #2Cancer hospitalNomun hospitalMurungeneral hospitalErdenet regionaldiagnostic and treatmentreferral centerKhovd regionaldiagnostic and treatmentreferral centerChoybalsan regionaldiagnostic and treatmentreferral centerRussiaChinaFigure 49-29. The public health approach to expanding laparoscopy to the regional diagnostic treatment and referral centers of Mongolia (RDTRCs). (Reproduced with permission from Intermountain Healthcare.)20050204060Percent of total cases801002006200720082009Year2010201120122013U1BAU1BR1BR1BR2R3BR3R4BR2R5BR4R5BR6BU2BU2BU1U3AU1Ap ˜ 0.001CROSSOVER FROM OPEN TO LAP CHOLE(SAGES)(SAGES)RURALURBANU1BAU1BR1BR1BR2R3BR3R4BR2R5BR4R5BR6BU2BU2BU1U3AU1A(SAGES)= Open= Laparoscopy= Plan for countrywide lap surgery expansion= Advanced course= Basic course= UrbanN= RuralN= Center numberABURNFigure 49-30. Transition from open to laparoscopic cholecystectomy in Mongolia. (Reproduced with permission from Wells


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Surgery_Schwartz. expansion= Advanced course= Basic course= UrbanN= RuralN= Center numberABURNFigure 49-30. Transition from open to laparoscopic cholecystectomy in Mongolia. (Reproduced with permission from Wells KM, Lee YJ, Erdene S, et al: Building operative care capacity in a resource limited setting: The Mongolian model of the expansion of sustainable laparo-scopic cholecystectomy, Surgery. 2016 Aug;160(2):509-517.)Brunicardi_Ch49_p2077-p2112.indd 210113/02/19 5:54 PM 2102SPECIFIC CONSIDERATIONSPART IIIntegrating Value into Global SurgeryAnother topic closely related to quality is the concept of value in healthcare, often described in terms of the value equation. The value equation states that value equals quality plus service, divided by cost. In this model, systems that generate high-quality care, at lower costs, produce greater value for stakeholders in that system (i.e., patients, physicians, insurers, and hospitals). This discussion is most pertinent in high-income countries such as the


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Surgery_Schwartz. at lower costs, produce greater value for stakeholders in that system (i.e., patients, physicians, insurers, and hospitals). This discussion is most pertinent in high-income countries such as the United States, where rising healthcare expenditures are cause for worry. It is also relevant in LMICs, where proposed interventions to improve quality must also control cost. A bidi-rectional exchange of information related to surgical systems between HICs and LMICs may provide one strategy for reduc-tion of cost in HICs and maximization of quality in LMICs.Advanced Surgical Care for Resource-Poor AreasLimited financial, physical, and human resources, political and social conflicts, and austere environments cause many to believe that advanced surgical care is inappropriate in resource poor countries.111,155-157 Misconception of the needs and abilities of people in LMICs cause some policymakers to discount the desire of people worldwide for advanced surgical care.144 Developing these


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Surgery_Schwartz. countries.111,155-157 Misconception of the needs and abilities of people in LMICs cause some policymakers to discount the desire of people worldwide for advanced surgical care.144 Developing these capabilities in resource-poor coun-tries has the potential to decrease overall cost and actually develop the infrastructure necessary to entice physicians and other healthcare workers to remain in their own countries. Establishing advanced surgical care requires expertise and ser-vices that symbiotically support and improve general medical care. Therefore, many developing countries are actively build-ing capacity and capability to provide the full spectrum of modern surgical care locally.158As economies improve and the benefits of laparoscopic surgery for resource-poor areas become better delineated, patients and doctors, surgical societies, ministries of health, and industries are demanding the benefits of minimally invasive surgery for patients and communities.150,159-165 The economic


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Surgery_Schwartz. patients and doctors, surgical societies, ministries of health, and industries are demanding the benefits of minimally invasive surgery for patients and communities.150,159-165 The economic impact of laparoscopy may be even greater in LMICs than in developed countries.166 Worldwide, surgeons have identified laparoscopic training as one of their greatest needs. In a 2010 survey, developing laparoscopic and endoscopic skills were identified as the most important skills desired by surgeons from the West Africa College of Surgeons (WACS) (Fig. 49-32).167Transplantation is another area of great interest to people in poor countries partly because of the high prevalence of kidney failure and because chronic dialysis facilities are limited. Hepatoma and liver failure are very common in countries with a strong prevalence of hepatitis B and C. Transplantation has become the treatment of choice for end-stage kidney disease in developed countries as it dramatically improves the qual-ity of life


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Surgery_Schwartz. with a strong prevalence of hepatitis B and C. Transplantation has become the treatment of choice for end-stage kidney disease in developed countries as it dramatically improves the qual-ity of life and increases survival rates compared to medical management.168 Yet, transplantation eludes most of the developing world. Initial attempts to transport critically ill patients from LMICs to developed countries for kidney transplantation were cost-prohibitive.169 With the alarming increase in the rate at which young people have been presenting with kidney disease in developing countries, the increased utilization placed on the few dialysis machines has been overwhelming.170 Dialysis units which previously were utilized three times a week, now oper-ate 24 hours a day, 7 days a week, and cannot begin to provide the needed services to the multitudes needing treatment. Even programs to develop peritoneal dialysis cannot fully ease the demand.12Remaining states without laparoscopic surgery


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Surgery_Schwartz. begin to provide the needed services to the multitudes needing treatment. Even programs to develop peritoneal dialysis cannot fully ease the demand.12Remaining states without laparoscopic surgery capabilityLaparoscopic Surgery expanded with internal Mongolian trainersLaparoscopic Surgery developed with HSUM/SFF/SAGES/U of U partnershipBayankhongorArhangaiKhovsgolZavkhanUvsKhentiiBayan-UlgiiBulganTuvDundgobiOmnogoviDomogoviKhovdGovi-altaiUvurkhangaiDornodSelengeDarkhanUulSukhbaatarOrkhonGobi-SumberFigure 49-31. Laparoscopic cholecystectomy expanded to 17 of 21 provinces in Mongolia by 2016. (Data from Raymond Price via personal communication with Dr. Erdene Sergelen. Illustration reproduced with permission from Intermountain Healthcare.)Brunicardi_Ch49_p2077-p2112.indd 210213/02/19 5:54 PM 2103GLOBAL SURGERYCHAPTER 49The majority of kidney transplants in developing countries are from living related donation because of cultural and legal prohibitions precluding cadaveric


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Surgery_Schwartz. 5:54 PM 2103GLOBAL SURGERYCHAPTER 49The majority of kidney transplants in developing countries are from living related donation because of cultural and legal prohibitions precluding cadaveric transplantation. Laparoscopic living related donation has the potential to increase the volun-tary donor pool as patients have less postoperative pain, return to work and activities quicker, and have much better cosmesis than open surgery.171 Ethical concerns exist for nonrelated dona-tions, however, because of concern for coercion in some coun-tries. Adapting to the limited resources, surgeons have described various cost-saving techniques to facilitate the laparoscopic approach in resource poor areas, such as using endoclips instead of staplers for vascular control, modifications to the surgical approach, and suprapubic extraction of the kidney rather than endocatch removal.171-173Academic Global SurgeryThere has been a paradigm shift from traditional reliance on intermittent short-term


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Surgery_Schwartz. approach, and suprapubic extraction of the kidney rather than endocatch removal.171-173Academic Global SurgeryThere has been a paradigm shift from traditional reliance on intermittent short-term volunteerism toward a strengthening of the education and research pillars for surgical healthcare in developing regions, a role ideally suited for academic sur-gery. Global surgery is emerging as a new academic field of endeavor (Table 49-12). Academic institutions have histori-cally pioneered discovery in disease causation and treatment. As globalization expands, academic surgical programs are begin-ning to respond by broadening their vision and mission. This vision and mission includes interdisciplinary and collaborative approaches to designing innovative, affordable surgical care that is accessible to all through research, education, development, and advocacy.174,175Responding to the challenges of disparities, new genera-tions of students, faculty, philanthropists, private industry


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Surgery_Schwartz. accessible to all through research, education, development, and advocacy.174,175Responding to the challenges of disparities, new genera-tions of students, faculty, philanthropists, private industry lead-ers, and policymakers have demonstrated a growing passion to address global surgery as part of global health.176,177 Prior to 1984, only 0.32% of physicians and 0.12% of nurses were involved in international health (either paid or volunteer).178 Recently, interest in global health has exploded among medical students, residents, and faculty in the United States.179,180Figure 49-32. West African College of Surgeons: most desired skills. CT = computed tomography; MRI = magnetic resonance imag-ing. (Adapted with permission from Akporiaye L. Trigen survey: West African College of Surgeons. Trigen, Lagos, Nigeria. Unpublished data. 2010. Illustration reproduced with permission from Intermountain Healthcare.)706050403020100Open surgical skills(suturing, dissection)Minimal access


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Surgery_Schwartz. Trigen, Lagos, Nigeria. Unpublished data. 2010. Illustration reproduced with permission from Intermountain Healthcare.)706050403020100Open surgical skills(suturing, dissection)Minimal access skillsEndoscopic skillsSurgical critical careIntraoperative respiratory &hemodynamic monitoringRadiologic image interpretation(ultrasound, CT, MRI)Ultrasound skillsTable 49-12Examples of academic global surgery programsINSTITUTIONNAME OF GLOBAL SURGERY CENTERBrigham and Women’s HospitalCenter for Surgery and Public HealthEmory University School of MedicineGlobal Surgery ProgramHarvard Medical SchoolProgram in Global Surgery and Social ChangeKing’s College LondonKing’s Center for Global Health and Health PartnershipsMcGill UniversityCentre of Global SurgeryOregon Health and Sciences UniversityGlobal Health Advocacy Program in SurgeryUniversity of British ColumbiaBranch for International Surgical CareUniversity of California San FranciscoCenter for Global Surgical StudiesUniversity of ChicagoGlobal


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Surgery_Schwartz. Advocacy Program in SurgeryUniversity of British ColumbiaBranch for International Surgical CareUniversity of California San FranciscoCenter for Global Surgical StudiesUniversity of ChicagoGlobal Surgery ProgramUniversity of UtahCenter for Global SurgeryBrunicardi_Ch49_p2077-p2112.indd 210313/02/19 5:54 PM 2104SPECIFIC CONSIDERATIONSPART IIAcademic involvement in global surgery provides train-ing for the next generation of surgical leaders where they can learn the necessary skills to develop systems for quality and affordable surgical care, both locally and internationally. Leaders for the 21st century will need to know how to provide outstanding cost-effective clinical care for all environments.Global Surgery programs use a variety of methods to engage faculty, residents, and students to foster an envi-ronment of creativity and innovation necessary to generate new ideas for solving some of the most vexing problems in global health. For example, some academic collabora-tive


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Surgery_Schwartz. to foster an envi-ronment of creativity and innovation necessary to generate new ideas for solving some of the most vexing problems in global health. For example, some academic collabora-tive programs introduce medical, engineering, and business students to the fascinating world of medical device innova-tion focusing on a variety of communities with very limited resources.181,182 Other academic endeavors include global surgery resident rotations, fellowships, journal clubs, classes (locally and online), certificates, Masters of Public Health, bilateral exchange programs, and a variety of educational, research, and entrepreneurial meetings (local, national, and international). Many of these activities provide opportuni-ties for collaborative scholarly work (journal publications, books, book chapters, films, grants, research trials) that pres-ent new avenues for academic advancement supporting both colleagues from abroad as well as the home institution. More importantly, Ministries of


Surgery_Schwartz

Surgery_Schwartz. chapters, films, grants, research trials) that pres-ent new avenues for academic advancement supporting both colleagues from abroad as well as the home institution. More importantly, Ministries of Health are responding to results of these scholarly works by designing policies that include surgi-cal care in their countrywide health plans.Partnering academic programs from high-income coun-tries with LMICs and/or with NGOs provides opportuni-ties for collaboration183 (Box: Academic Global Surgery 13Global surgery engagementsLEVEL OF INTEGRATIONAssociationAllianceCollaborationPartnership+–Figure 49-33. Training outcomes from NGO/academic partner-ship. (Reproduced with permission from IVUmed and Intermoun-tain Healthcare.)Academic Global Surgery PartnershipsA. Rwanda Human Resources for Health (HRH) ProgramThe Rwanda Human Resources for Health (HRH) program is an ambitious 7-year long program of the Ministry of Health (MOH) of Rwanda, funded by the U.S. Government and the Global Fund to


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Surgery_Schwartz. (HRH) ProgramThe Rwanda Human Resources for Health (HRH) program is an ambitious 7-year long program of the Ministry of Health (MOH) of Rwanda, funded by the U.S. Government and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The HRH Program seeks to greatly expand and improve Rwanda’s health care workforce by strengthening national training programs of specialized physicians, nurses, oral health providers, and health managers. The HRH Program is also designed to strengthen the capacity of academic institutions in Rwanda to sustain the training programs initiated and supported by the HRH Program through (a) recruitment and retention of Rwandan faculty, (b) transfer of knowledge and skills to Rwandan faculty, (c) establishment of additional academic partnerships and collaborations between Rwandan academic institutions and U.S. academic institutions. Currently, 22 U.S. academic medical centers and universities are participating in this program, in collaboration with the


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Surgery_Schwartz. between Rwandan academic institutions and U.S. academic institutions. Currently, 22 U.S. academic medical centers and universities are participating in this program, in collaboration with the University of Rwanda—College of Medicine and Health Sciences (UR-CMHS) training faculty. Since the launch of the program in 2012, U.S. institutions have deployed about 100 faculty members per year across these four health-related professions. The recruited U.S. faculty are twinned with UR faculty and senior trainees, paired along common goals and interests, and together they engage in a diversity of activities—including teaching, training, research, clinical care, and care delivery improvement projects.The program is currently in its fifth year (August 2016–July 2017). Focusing our discussion on the surgical disciplines, the annual intake of postgraduate students (residents) has dramatically increased. The anesthesiology residency, whose annual matriculation ranged from zero to three residents,


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Surgery_Schwartz. surgical disciplines, the annual intake of postgraduate students (residents) has dramatically increased. The anesthesiology residency, whose annual matriculation ranged from zero to three residents, now routinely admits 10 new residents yearly. The surgery residency has divided into the four specialties of general surgery, orthopedics, urology, and neurosurgery. Annual matriculation across all for programs now ranges from 15 to 20 compared to 3 to 6, prior to the HRH program’s support of the surgery department. In July 2016, UR graduated eight new general surgeons and one new urologist, the largest output to date. Similar training output is noted across the other disciplines and specialties as well. As a result, Rwanda is now on track to achieve most of its targets for the health workforce. Most graduates are deployed across provincial hospitals to provide specialty level care in a decentralized fashion, while a portion are maintained at the teaching hospitals to be recruited as new


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Surgery_Schwartz. Most graduates are deployed across provincial hospitals to provide specialty level care in a decentralized fashion, while a portion are maintained at the teaching hospitals to be recruited as new faculty. The HRH Program also aims to strengthen the quality of the training programs through competency-based training and pedagogic innovation, improvements in infrastructure and equipment within the schools at the CMHS and the teaching hospitals, and stronger administration of the training programs. As the HRH program comes into its final years, efforts are underway towards faculty professional development program that will both ensure that the UR-CMHS is able to Partnerships). Global surgery engagements exist along a con-tinuum from simple associations, to alliances, collaborations, or formal partnerships (Fig. 49-33). A true partnership usually involves specified and joint rights and responsibilities. The other engagements vary depending on the amount of integra-tion between the


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Surgery_Schwartz. formal partnerships (Fig. 49-33). A true partnership usually involves specified and joint rights and responsibilities. The other engagements vary depending on the amount of integra-tion between the institutions and organizations. Successful sustainable progress for global surgery can occur within any of the different levels of engagement. Many partnerships begin with a simple association or alliance before growing into a formal partnership.Academic Global Surgery helped progress the founda-tional knowledge in defining the burden of surgical disease, clarifying the cost-effectiveness of surgical care, and estab-lishing baseline values of surgical capacity.184 Further work is necessary to move beyond data collection and to use this foun-dational knowledge to now develop interventional strategies and stimulate sustainable solutions for accessible, affordable, appropriate surgical care for all.185Brunicardi_Ch49_p2077-p2112.indd 210413/02/19 5:54 PM 2105GLOBAL SURGERYCHAPTER


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Surgery_Schwartz. strategies and stimulate sustainable solutions for accessible, affordable, appropriate surgical care for all.185Brunicardi_Ch49_p2077-p2112.indd 210413/02/19 5:54 PM 2105GLOBAL SURGERYCHAPTER 49continue making the aforementioned human resource gains independent of this large foreign aid grant, and that the relationships and collaborations forged between academic institutions may continue to grow and find new avenues for productive work together.186—Robert Riviello, MD, MPH, FACSB. Coordinating Nongovernmental Organizations (NGO) and Academic Organizations: IVUmedNonprofit organizations (NGO) have filled a niche in establishing surgical care in countries where training centers and healthcare systems are historically nonexistent or understaffed. More recently, professional organizations have developed a focus on specific diseases or patient groups and have become a resource for education and training in poor countries.For more than 20 years, the IVUmed NGO has focused on urological


Surgery_Schwartz

Surgery_Schwartz. have developed a focus on specific diseases or patient groups and have become a resource for education and training in poor countries.For more than 20 years, the IVUmed NGO has focused on urological education and hands-on training in Africa, Asia, and Latin America. IVUmed evolved from a need identified by plastic surgeons that had seen many children with hypospadias and other urological anomalies, such as exstrophy, when providing care for children with cleft lip and palate. Adult surgeons were not trained in the delicate reconstruction of pediatric genitourinary anomalies, and pediatric surgeons were not trained in endoscopic or reconstructive urological surgery. The program has expanded to support training in all aspects of urological care, including adult reconstruction, oncology, and endoscopic management of stones and prostatic disease.As a nonprofit organization, IVUmed is a partnership between surgeons, anesthesiologists and nurses, academic medical centers, urological


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Surgery_Schwartz. and endoscopic management of stones and prostatic disease.As a nonprofit organization, IVUmed is a partnership between surgeons, anesthesiologists and nurses, academic medical centers, urological professional associations, industry, and the public with urologic surgery training in more than 20 countries. It also provides North American trainees scholarships to travel to low-resource countries to learn and to share knowledge gained in their own programs. Many former scholars become mentors for other residents when they complete their training. The sites with the longest collaborations have developed their own educational programs in general urology or subspecialty areas and are now providing advanced training and care locally (see Fig. 49-33).C. Cancer Disparities Consortium in West AfricaNoncommunicable diseases, such as cancer, are a major public health problem in lowand middle-income countries (LMIC). In many LMIC, surgeons, due to the lack of medical oncologists, treat all stages


Surgery_Schwartz

Surgery_Schwartz. diseases, such as cancer, are a major public health problem in lowand middle-income countries (LMIC). In many LMIC, surgeons, due to the lack of medical oncologists, treat all stages of noninfectious related cancers, such as breast and colorectal cancer (CRC). In 2011, to address the disparity in outcomes for patients with cancer in West Africa compared to the United States, a research and training collaboration was formed between the Obafemi Awolowo University Teaching Hospital in Nigeria and Memorial Sloan Kettering Cancer Center (MSK) in New York. This relationship has now grown to become a consortium of five Nigerian hospitals and the Global Cancer Disparity Initiative Team at MSK.The consortium began by focusing on important questions regarding CRC: how can early stage patients be identified; what are the demographics of CRC patients in Nigeria; and is the biology of CRC different in Nigeria compared to the USA? These questions are being answered, with the support of two NIH


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Surgery_Schwartz. identified; what are the demographics of CRC patients in Nigeria; and is the biology of CRC different in Nigeria compared to the USA? These questions are being answered, with the support of two NIH grants, by creating a robust prospective database with a matching biobank. With over 250 patients, the consortium can now describe the metastatic patterns, stages of presentation, and risk factors for CRC in West Africa. Given that over 65% of patients present with stage IV disease, the development of a risk model to identify patients with early stage disease is a priority. This is being accomplished with a 400-patient prospective trial of colonoscopy in patients over 45 years of age with rectal bleeding in three Nigerian cities. Future projects include studying new technologies for CRC and breast cancer screening.—Peter Kingham, MD, FACSEthicsThe ethics involved in working outside one’s own country are complex. While a practitioner’s scope of practice is usually constrained by regulation


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Surgery_Schwartz. cancer screening.—Peter Kingham, MD, FACSEthicsThe ethics involved in working outside one’s own country are complex. While a practitioner’s scope of practice is usually constrained by regulation in America and Europe, in many countries the limits of what one can do are neither regulated nor enforced. Guidelines for what should be done, where, and under what circumstances are beyond the expertise of some ministries of health. Some problems are so episodic that they are not anticipated, and few guidelines exist. For example, in natural disasters and emergencies, should any willing provider from any country be granted permission to provide care? Should specific disaster-related training be encouraged or required?187,188 In the nonacute setting, should practitioners not licensed or credentialed in their home environments be allowed to perform volunteer surgery in other countries? What entity should oversee the flow of volunteer practitioners? Can a standard set of guidelines meet the


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Surgery_Schwartz. in their home environments be allowed to perform volunteer surgery in other countries? What entity should oversee the flow of volunteer practitioners? Can a standard set of guidelines meet the needs of most countries? Currently, there is little cross-national agreement between state entities, like ministries of health and independent organizations and individuals. While many countries require at least temporary licensure, some do not. In many cases enforce-ment is inconsistent.With respect to research, the poor historically have not received benefit from research performed on them. In inter-national studies, even local collaborators have been left out of study design and publication.189 As internet communications have improved, these lapses are no longer tolerated.190 Informed consent for surgical procedures, in the appropriate language and respectful of local customs, is becoming the norm. Few hospitals outside academic medical centers have institutional review boards (IRBs) to


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Surgery_Schwartz. for surgical procedures, in the appropriate language and respectful of local customs, is becoming the norm. Few hospitals outside academic medical centers have institutional review boards (IRBs) to oversee the implementation and review of clinical research. In recent years, peer reviewed journals have become more mindful of attribution of credit, and authors are strongly encouraged to design and report studies with local input at all levels.With regard to transplantation, many countries have laws against cadaveric transplants because of the very real concern for illegal marketing of organs. Even living-donor Brunicardi_Ch49_p2077-p2112.indd 210513/02/19 5:54 PM 2106SPECIFIC CONSIDERATIONSPART IItransplantation has seen effects of coercion in some regions and for some populations such as prisoners. Nevertheless, the need and popular desire for transplantation is accelerating acquisition of skills and technology to make transplantation available worldwide.191Finally, what is


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Surgery_Schwartz. such as prisoners. Nevertheless, the need and popular desire for transplantation is accelerating acquisition of skills and technology to make transplantation available worldwide.191Finally, what is considered ethical in one country or com-munity might be considered highly unethical in another. Con-sent for surgery may in one setting rest with the patient, but in another, with the community or family. Values about privacy vary markedly from region to region. Health information in many cultures is considered to be a community concern, not the personal property of an individual patient.Innovation in Global SurgeryThe pressing need for surgical care at all levels and the shortage of fully trained surgeons, anesthesiologists, and support personnel as well as equipment and supplies means that opportunities abound for innovation. Innovations in education, including simulation, can shorten the time necessary for learn-ing technical skills. Gaming technology can teach algorithms for


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Surgery_Schwartz. that opportunities abound for innovation. Innovations in education, including simulation, can shorten the time necessary for learn-ing technical skills. Gaming technology can teach algorithms for interpretation of X-rays and ultrasounds. Telemedicine/tele-health is transforming education through combinations of clini-cal case-based learning and massively open online courses (MOOC) (Box: Telemedicine). The potential for education innovation in surgery beyond the apprenticeship system cham-pioned by Halsted in 1904 is vast.14Sophisticatedtechnology thatsimplifiesLow-cost,innovativebusiness modelsEconomicallycoherent valuenetworkRegulations and standards thatfacilitatechangeFigure 49-34. Elements of disruptive innovation. (Reproduced with permission from Intermountain Healthcare.)Innovation that radically changes the way we do things and that changes a paradigm of a service or system is called “disruptive”; it abruptly changes an older and more expensive system in favor of a less