Surgery

Chapter 67 Surgery

Haile T. Debas, Richard Gosselin, Colin McCord, and Amardeep Thind

Countries with developing economies have not considered surgical care to be a public health priority, yet surgically treatable conditions--such as cataracts (Javitt 1993); obstructed labor (Neilson and others 2003); symptomatic hernias (Olumide, Adedeji, and Adesola 1976; Rahman and Mungadi 2000); osteomyelitis (Bickler and Rode 2002; Hilton 2003); otitis media (Smith and Hatcher 1992; Whitney and Pickering 2002); and a variety of inflammatory conditions--add a chronic burden of ill health to populations. These acute and chronic conditions take a serious human and economic toll and at times lead to acute, life-threatening complications.

Inadequacies in the initial care of injured patients (Hyder and Peden 2003; Jat and others 2004; Mock 2003; Mock and others 1995); of women with obstructed labor; and of children with treatable congenital anomalies, such as clubfoot (Ponseti 1999; Turco 1994) lead to preventable deaths or to chronic disabilities that make productive employment impossible and impose dependency on family members and society.

The role of surgery as a preventive strategy in public health needs to be studied and measured far more extensively than is currently the case. Another key reason for this study is that virtually all countries are developing their economies, and as a result, developing nations are increasingly facing a double burden--that is, the infectious diseases that have historically been so relevant and the conditions that emerge with economic development (for example, trauma from motorcycle, truck, and car accidents). The inclusion of a surgery chapter in this book recognizes that surgical services may have a cost-effective role in population-based health care. Recent studies (for instance, McCord and Chowdhury 2003) show that basic hospital service, which requires no sophisticated care, can be cost-

effective, with a cost per disability-adjusted life year (DALY) that is much lower than might have been expected, and can be on a par with other well-accepted preventive procedures, such as immunization for measles and tetanus and home care for lower respiratory infections (Armandola 2003; Dayan and others 2004; Moalosi and others 2003; Ruff 1999).

We have identified four types of surgically significant interventions with a potential public health dimension: (a) the provision of competent, initial surgical care to injury victims, not only to reduce preventable deaths but also to decrease the number of survivable injuries that result in personal dysfunction and impose a significant burden on families and communities; (b) the handling of obstetrical complications (obstructed labor, hemorrhage); (c) the timely and competent surgical management of a variety of abdominal and extra-abdominal emergent and life-threatening conditions; and (d) the elective care of simple surgical conditions such as hernias, clubfoot, cataract, hydroceles, and otitis media.

NATURE, CAUSES, AND BURDEN OF SURGICAL CONDITIONS

Surgery is at the end of the spectrum of the classic curative medical model and, as such, has not been routinely considered as part of the traditional public health model. However, no matter how successful prevention strategies are, surgical conditions will always account for a significant portion of a population's disease burden, particularly in developing countries where conservative treatment is not readily available, where the incidence of trauma and obstetrical complications is high, and

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where there is a huge backlog of untreated surgical diseases (Murray and Lopez 1996). Some surgical procedures can certainly be perceived as forms of secondary or tertiary prevention. Since the publication of the first edition of this book, which did not have a chapter on surgery, the health care community has recognized that the surgical management of some common conditions can indeed be a cost-effective intervention (Javitt 1993; McCord and Chowdhury 2003). The purpose of this chapter is to explore this hypothesis in more depth.

Methods for Determining Burden of Surgical Disease

We have arbitrarily decided to define a surgical condition as any condition that requires suture, incision, excision, manipulation, or other invasive procedure that usually, but not always, requires local, regional, or general anesthesia. We prefer this definition for two main reasons, to one that would define surgery as procedures performed by trained surgeons. First, surgery does not have to be performed by qualified surgeons. Indeed, in developing countries with few doctors, nondoctors can be trained to perform several types of operations satisfactorily. Second, we believe that the concept of surgery should include minor surgical procedures that nurses or general practitioners could perform along with nonoperative management of surgical diseases (for example, certain types of abdominal, thoracic, or head trauma and burns and infections). Any definition of surgery will have limitations, as has ours, and those limitations must be kept in mind when making interpretations, extrapolations, or estimates. Our broad definition is compatible with the concept of regionalized, coordinated, and interdependent services provided at the community clinic level and at the district and tertiary hospital levels. The most difficult task we then face is trying to determine the burden of surgical conditions as measured in DALYs. To our knowledge, this measurement has never been attempted. What we provide here is a starting point, with the understanding that the calculations will change as data are developed.

Our methodology was based on data from the World Health Report 2002: Reducing Risks, Promoting Healthy Life (WHO 2002) and the global burden of disease study (Murray and Lopez 1996). We began by listing all the conditions for which surgery might be indicated into three groups, with group I being communicable diseases, group II being noncommunicable diseases, and group III being injuries. We then undertook a comprehensive literature review for each condition to determine the proportion of the total burden of disease attributable to it and the proportion of the burden that could be prevented or treated by surgery. Essentially, we found no data of value except maybe for cataracts (group II-F), for which a single intervention (intraocular lens removal with or without implant) is or should ultimately be indicated for nearly 100 percent of patients (Dandona and others 1999; Javitt 1993).

The World Health Report 2002 attributes 8,269, of a total 1,467,257,000 DALYs, to cataracts (0.56 percent), and all those DALYs are considered potentially surgical. Maternal conditions (group I-C), perinatal conditions (group I-D), diabetes (group II-C), intentional injuries (group III-B), and unintentional injuries (group III-A), to name a few, are much broader categories of conditions for which the demarcation between the surgical and nonsurgical burden is not as clear as for cataracts.

Faced with a near total lack of pertinent data, we decided that the next best approach was to try to obtain consensus on a "best educated guess" for the surgical burden of each condition. We developed a survey instrument that listed all the possible surgical conditions (all potential surgical DALYs representing the maximum imaginable DALYs that could conceivably be surgical). We sent the questionnaire to 32 surgeons in various parts of the world, asking them what was, in their opinion, the proportion of each condition that would require surgery, which we have referred to as estimated surgical DALYs or the conservative minimum. For each of the 18 completed questionnaires, we discarded the two lowest and two highest values for each condition, leaving a sample of 14 surveys. The lowest value of this sample was consistently chosen so as to err systematically on the conservative side. Note that more than 90 percent of all retained values were within 10 percent of the chosen value. We then applied this value to the DALY numbers provided by the World Health Report 2002 for each category of potentially surgical conditions.

Findings

Table 67.1 presents our estimates of the actual surgical burden for each category of potential surgical conditions for the world as a whole and by region. The table indicates that conditions requiring surgery account for a significant proportion of DALYs. Developing more refined, region-specific information to help policy makers will require more detailed data on the burden of surgical diseases (diseases requiring surgical treatment) and on the cost-effectiveness of surgical therapy. To this end, an extremely helpful step would be for international surgical associations to regularly monitor the disease burden attributable to surgical conditions throughout the world.

A few salient points about the burden of surgical diseases can be made from data provided in table 67.1. We estimate very conservatively that 11 percent of the world's DALYs are from conditions that are very likely to require surgery. Our estimated figures are as high as 15 percent for Europe and as low as 7 percent for Africa. Estimated surgical DALYs for the world are 27 per 1,000 population. The estimated figure is about twice as much for Africa (38 per 1,000) as for the Americas (21 per 1,000).

Table 67.2 summarizes the burden of common surgical conditions based on World Health Report 2002 data. A more

1246 | Disease Control Priorities in Developing Countries | Haile T. Debas, Richard Gosselin, Colin McCord, and others

Table 67.1 Estimated Surgical DALYs by Region

Region

World Africa Americas Eastern Mediterranean Europe Southeast Asia Western Pacific

Source: WHO 2002 and authors' estimates.

Total DALYs (millions)

1,468 358 145 137 151 419 258

Estimated surgical DALYs (millions)

164 25 18 15 22 48 37

Estimated surgical DALYs as a percentage of total DALYs

11 7 12 11 15 12 15

Table 67.2 Burden of Common Surgical Conditions

Condition

Injuries Malignancies Congenital anomalies Obstetrical complications Cataracts and glaucoma Perinatal conditions Other

Estimated (millions)a

63 31 14 10 8 7 31

Surgical DALYs

Percentage 38 19 9 6 5 4 19

Estimated surgical DALYs as a percentage of total DALYs

4.3 2.1 1.0 0.7 0.5 0.5 2.1

Source: WHO 2002 and authors' estimates. a. Estimated surgical DALYs refers to our conservative estimate of DALYs averted by surgical treatment in the most likely diseases for the most likely indications.

Estimated surgical DALYs per 1,000 population

27 38 21 30 25 31 22

Estimated surgical DALYs per 1,000 population

10 5 2 2 1 1 5

detailed look at these data allows us to make the following observations:

? Injuries account for 63 million DALYs, or about 4 percent of all DALYs and 38 percent of the world's estimated surgical DALYs.

? Surgical infections, including infected wounds, superficial and deep abscesses, septic arthritis, and osteomyelitis, undoubtedly account for a significant portion of surgical DALYs, but the available data do not permit quantification.

? Surgical DALYs pertaining to acute abdominal conditions, including appendicitis, intestinal obstruction, gastrointestinal bleeding, hernias, and blunt or penetrating injuries also cannot be calculated because of the lack of data.

? Approximately one-third of maternal conditions, including hemorrhage, obstructed labor, and obstetrical fistulas, are surgical, and these represent 10 million DALYs, or 0.7 percent of all DALYs.

? Congenital anomalies refer to an ill-defined grouping of disparate pathologies that includes congenital malformations such as cleft lip and palate, hernias, anorectal malformations, and clubfoot. We estimate that some 50 percent of congenital anomalies are surgical, representing about 14 million DALYs, or 1 percent of all DALYs.

? Malignancies account for 31 million surgical DALYs, or slightly more than 2 percent of all DALYs.

Table 67.3 breaks down the burden of common surgical conditions by region, also showing rates per 1,000 population. The absolute burden of injuries is highest in Southeast Asia, followed by the Western Pacific and Africa. In terms of population rates, whereas injuries account for 10 DALYs per 1,000 population for the world, the estimated figure is almost twice as much for Africa (15 per 1,000) as for Europe (8 per 1,000). Similarly, rates of obstetrical complications are far higher in Africa than elsewhere, at 6 DALYs per 1,000 population. In

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Table 67.3 Estimated Surgical DALYs by Condition and Region (DALYs in millions followed by DALYs per 1,000 population in parentheses)

Condition Injuries Obstetrical complications Cataracts and glaucoma Malignancies Perinatal conditions Congenital anomalies Other

Africa

10 (15)

4 (6)

1 (2)

2 (3)

2 (3)

2 (3)

4 (6)

Source: WHO 2002 and authors' estimates.

Americas

7 (8) 1 (1)

(0.5) 4 (5) 1 (1) 2 (2) 3 (4)

Eastern Mediterranean

6 (12)

1 (2)

1 (2)

1 (2)

1 (2)

2 (4)

3 (6)

Europe

7 (8)

(0.5) 1 (1) 8 (9)

(0.5) 1 (1) 5 (6)

Southeast Asia

20 (13)

3 (2)

3 (2)

6 (4)

3 (2)

4 (3)

9 (6)

Western Pacific

13 (8)

1 (1)

2 (1)

10 (6)

1 (1)

3 (2)

7 (4)

contrast, Europe has the highest rate of surgical DALYS related to malignancies--9 per 1,000 population.

All these estimates are debatable. Work is needed to obtain more valid, accurate, and reliable data, but in the meantime, we believe that our results represent a conservative and acceptable baseline estimate of the burden of surgical conditions against which prospectively gathered data for given interventions can be compared in order to assess the extent to which they address the burden. In addition, the burden needs to be monitored over time. Evidence suggests that the burden of intentional and unintentional injuries is rising, particularly in Sub-Saharan Africa and the Middle East. Some of the important contributing risk factors include (a) aging populations; (b) increased access to and use of mechanized vehicles and tools without commensurate improvements in roads, traffic control systems, or capacity for trauma care; and (c) persistent armed conflicts (Kaya and others 1999; Krug, Sharma, and Lozano 2000; Meyer 1998; Mock and others 1995, 1999; Nantulya and Reich 2002; Peden and Hyder 2002).

INTERVENTIONS

Both population-based strategies and personal sevices provided in community clinic, district, and tertiary hospitals are considered in this section.

Population-Based Strategies Population-based approaches to the prevention of unintentional and intentional injuries are discussed in the chapters on

those topics. A population-based approach to injury should not, however, be limited to injury prevention. Patients may survive their primary injuries only to become chronically disabled and a burden to their families and to society (Krug, Sharma, and Lozano 2000; Mock and others 1999; Nantulya and Reich 2002; Peden and Hyder 2002). The incidence and severity of the complications of survivable injury may be significantly lessened by the provision of adequate surgical care during prehospital care and initial hospitalization. No published data from developing countries are available, however, either to prove this plausible contention or to quantify the benefits of adequate initial surgical treatment. A strategy to prevent chronic disability arising from survivable injury requires wellcoordinated services for resuscitation, evacuation, and early and expert operative management of the initial injury.

Many other surgical conditions that can be treated electively, such as hernias, hydroceles, and otitis media, are treated when they present with complications requiring emergency surgery. Thus, a pertinent question is whether treating such conditions electively would be more cost-effective, but no reliable data are available to answer this question positively or negatively.

Population-based strategies could also be applied to prevent or treat some musculoskeletal conditions. For example, the incidence of clubfoot is estimated at 1 or 2 per 1,000 live births, but in developing countries these children are typically brought in for orthopedic care when it is too late for effective nonsurgical conservative management (Ponseti 1999; Turco 1994). Because we have no baseline data for the burden of clubfoot and other musculoskeletal conditions, we are unable to

1248 | Disease Control Priorities in Developing Countries | Haile T. Debas, Richard Gosselin, Colin McCord, and others

quantify the DALYs that could be averted by comprehensive surgical care.

The following sections describe the organization of surgical services that we think would begin to provide coordinated surgical care in developing countries. The provision of surgical services in developing countries requires organizational structure and capacity at the level of community-based clinics, district hospitals, and tertiary care hospitals. Our concept of minimally adequate modules of surgical care is informed by our personal experiences, the experiences of others, and a recent World Health Organization report (WHO 2003). We recognize that to accommodate local needs and reality on the ground, any proposed plan to develop surgical services must be flexible. Table 67.4 presents our estimates of the needs for infrastructure, equipment and supplies, and workforce for the three levels of surgical care: community clinic, district hospital, and tertiary hospital.

Community Clinics

Table 67.4 shows resource and workforce requirements and types of surgical services a community clinic could provide for a population of around 20,000. We assume that surgical services in community clinics would be provided at no cost to patients. A cost-recovery system would be unlikely to succeed everywhere but, if implemented, should be equitable, with payments adjusted to patients' ability to pay. A mechanism for accountability and monitoring should be established to avoid the misuse of drugs and supplies. Simple patient records should be maintained, including outcomes of treatment and use of supplies. Even though the community clinic described here is what we think it should be as opposed to what we know it to be, our model may serve the needs of rural areas in developing countries and could provide a starting point for estimating costs.

District Hospitals

The next level of organization of surgical services is the district hospital, which in addition to providing primary care for the local population would also provide secondary-level surgical services and serve as a referral center for a number of community clinics in a defined region. In turn, the district hospital would ideally refer patients requiring complex surgical care to a tertiary-level hospital, but we recognize that such referral cannot always be achieved in practice because of transportation limitations, economic constraints, and prevalent social and cultural contexts. District hospitals vary in size from as small as 10 to 20 beds to as large as 200 to 300 beds and vary in their degree of sophistication in relation to diagnostic and therapeutic capabilities. For this discussion, we have arbitrarily chosen to focus on district hospitals with 100 beds or fewer.

Table 67.4 shows the infrastructure requirements for this type of hospital. Patients requiring more complex imaging studies and laboratory tests would be referred to the tertiary hospital.

To the extent possible, all equipment and supplies (table 67.4) should be standardized, and an efficient and reliable system for maintenance and replacement should be ensured. Operating room instruments and supplies should be available to enable the performance of laparotomy, thoracotomy, obstetrical and gynecological procedures, treatment of extremity fractures, skin grafting, and emergency burr hole of the skull. These instruments should be available at least in duplicate. Table 67.4 also shows workforce needs and the types of surgical procedures that may be performed in a district hospital.

The district hospital is assumed not only to serve as the referral hospital for community clinics, but also to coordinate the community clinics in its own region as a single operating unit, assuming responsibility for wireless communication, training the workforce, providing continuing medical education, and monitoring the quality and outcome of care. It would also provide primary care to its contiguous population.

Tertiary Hospitals

The tertiary hospital would function as the referral center for all complex surgical care in a region, country, or group of countries. Ideally, but depending on the country's resource constraints, it would provide the full range of care shown in table 67.4. The tertiary hospital would also provide primary surgical care for its local population and could take on the role of a teaching hospital for doctors, nurses, and other health care workers.

In the proposed organizational structure, the tertiary hospital is viewed as the top of a pyramid of surgical services, with several district hospitals referring patients requiring complex surgical care to the tertiary hospital. As such, it should also take the primary responsibility for coordinating and collaborating with all the district hospitals and community clinics in its area of responsibility to ensure that surgical care is available throughout the region and that well-functioning wireless communication and ambulance systems are available. If a regionalized system of separate ambulance services is not available, the tertiary hospital can provide the ambulance services required. Specialists in the tertiary hospital should provide telephone and electronic consultation for doctors and nurses in district hospitals. The tertiary hospital should also coordinate and monitor the quality of care in the region that serves as its referral base, undertake clinical outcome studies, and provide continuing medical education. In addition, it should be the main teaching hospital for medical students, nurses, and technicians, with the district hospitals and even the community clinics serving as clinical rotation sites for trainees. This organizational

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