5 Questions: Thomas Weiser on improving access to surgical care worldwide

For many years, surgery has largely been ignored as an integral part of public health, despite the fact that two-thirds of the world’s population lacks access to safe, affordable surgery and anesthesia care. Now, two new reports — one from the Lancet Commission on Global Surgery and another from the World Bank — quantify the burden of this unmet need and provide compelling new evidence to inspire action.

Thomas Weiser, MD, assistant professor of surgery at the School of Medicine, was involved in the production of both reports, serving as an adviser to the Lancet Commission’s Global Surgery 2030 report, and as a co-author of the “Essential Surgery” volume of Disease Control Priorities 3, a publication from the World Bank.

Weiser has spent the last decade working to improve surgical services in resource-poor settings, particularly in low- and middle-income countries. As a fellow at the Harvard School of Public Health, Weiser was part of the World Health Organization Safe Surgery Initiative. He worked closely with surgeon, author and global health researcher Atul Gawande, MD, MPH, to introduce a safety checklist in operating rooms around the world. His current work focuses on the quality and cost-effectiveness of care, and strategies for improving the safety and reliability of surgical care.

Weiser recently spoke with global health writer Rachel Leslie about some of the latest research driving renewed interest in global surgery.

Q: When did you become interested in global surgery?

Weiser: I was always interested in working abroad, even before becoming a doctor. I realized I wanted to become a trauma surgeon during medical school, so it was natural for me to connect the two. At the time, the only real options to practice surgery in the global setting were mission-style trips for a week or two, or a career as a “bush doctor” working long term in a hospital or health facility. I was more interested in how systems of care were established and supported, and how such systems could support surgical capacity.

When I applied to residency in 2001, I was surprised to find that this was a totally foreign concept for surgeons, despite the U.S. having long pioneered trauma systems for care of the injured. I knew there was a need for developing systems of care for surgical patients globally, but because there were no data, and no one was really asking the question, there was not much interest in the subject.

Q: How big is the current gap in access to basic surgical care worldwide?

Weiser: There are at least 143 million additional operations needed to meet the basic disease burden and surgical conditions affecting people living in low- and middle-income countries, or LMICs. Of the 313 million operations performed in 2012, only 6 percent were performed in LMICs, where over a third the world’s population lives.

There are tremendous disparities in access to and provision of care, but bigger still is the variability in outcomes following surgery. For example, death rates for cesarean section are orders of magnitude higher in poorly resourced settings. Such death rates would be unacceptable in the U.S., yet this is a fact of life for most of the world. I suspect the variability in access, provision and outcomes of care are as high, if not higher, within countries as between them, indicating that many places could quickly improve if the right policies were implemented and investments made.

Q: Why has it taken so long for global surgery to gain attention on the public health agenda?

Weiser: The biggest barrier has been a complete lack of data. Surgery is a therapy, not a disease, and does not fit nicely into a box that can generate interest and support. Most public health priorities focus on a disease entity, or specific health condition, and use vertical programs to address the problem.

Many of these programs are developed in parallel to a poorly functioning health system. Vaccines are a great example. Delivering vaccinations to a population requires a cadre of community workers, training, materials and a cold chain — a supply chain in which a product, in this case vaccines, can be maintained at a certain temperature or temperature range while being transported. Much of this can be done with the support of the health system and ministry, but vaccination campaigns do not necessarily strengthen the health system.

Surgery, however, is too complex to be undertaken without a strong health-delivery program. It requires a strong and continuous supply chain, highly technical skills and ongoing training, and intensive management to organize such services. It was previously considered too expensive and cost-ineffective, although there were no data to support such suppositions. In fact, we now know investing in surgery is incredibly cost-effective, and although building surgical capacity from nothing would require substantial capital investment, the returns to the health system and the overall health of the population would be tremendous.

Q: Can countries afford to invest in global surgery?

Weiser: The Lancet Commission estimates that over the next 15 years, global output will lose $20 trillion in productivity due to surgical conditions. Of this loss, well over half, or $12 trillion, will come from LMICs with low surgical rates. To bring LMICs up to par with their assessed needs, however, would require an investment of some $300-$400 billion over the same time period. While this investment seems huge, it is actually a good purchase when measured against a $12 trillion loss in these same countries.

There are additional gains that were not included in the commission’s assessment, making this appraisal a likely underestimate. As I mentioned, investing in surgical capacity, infrastructure and skills are a foundational component of strengthening health systems more generally, and would yield additional health savings in other, nonsurgical diseases. For example, improvements in supply chains and resource management, which are necessary to the scale-up of surgical interventions, will have profound effects not just on the health system, but in many other nonmedical sectors. Strengthening surgical capacity is, in my opinion, health-system strengthening.

Q: What impact do you hope these findings will have in shaping public health policy?

Weiser: First and foremost is the pulling back of the curtain on what the state of surgery is around the world. Understanding the disparities in access to and outcomes of care, the health and economic consequences, and the effects of improved delivery, safety and quality of surgical care are all essential if we are to generate interest in the issues and commitments to making care better, safer and more equitable.

I hope that these findings and the new data presented in the commission report will increase attention and awareness of the vital role surgical care plays in a health system. Ideally we will see increased leadership from organizations like the WHO and the World Bank in the form of attempts to standardize data collection, identify high-performing health systems, publicize successful programs and promote their adoption and replication in other health settings, and support improved investments in surgical capacity and quality improvement as a way to strengthen the health system more generally.