A new metric of surgical capacity

On September 28, 2010, in research, surgery, by Karen Grepin
Perhaps the bigger “global health winner” of the UN MDG Summit held this past week in New York City was reproductive, newborn and child health.  The UN announced a new “Global Strategy for Women’s and Children’s Health” – and backed up by $40 billion in commitments to fund the strategy.  The Bill and Melinda Gates Foundation announced a new Alliance to support Country-Led Reproductive, Newborn, and Child Health initiatives.

Key to reducing maternal mortality is to ensure that, when needed, women have access to emergency obstetric care, including the capacity to surgically deliver her baby.  This point at times get lost with the justified focus on family planning, skilled birth attendants, and facility-based births.  As I have highlighted on this blog before, the accessibility of safe surgery is poor in many developing countries and is likely limiting the availability of such life saving technologies.

In this past week’s lancet, there is another excellent study that points to the need for increased investment in surgical infrastructure.  The metrics available to measure and monitor surgical availability is poor – no surprise – but the authors of a new study have used the availability pulse oximetry as a “proxy for adequacy of operating theatre equipment supply because of this scarcity in low-income settings, and because international organisations such as the World Federation of Societies of Anaesthesiologists (WFSA) and WHO regard it as essential for safe anaesthesia and surgery.”  Sounds reasonable.

Not terribly surprisingly, they find that availability is poor in many parts of the world, specifically they find:

The estimated number of operating theatres ranged from 1·0 (95% CI 0·9–1·2) per 100 000 people in west sub-Saharan Africa to 25·1 (20·9–30·1) per 100000 in eastern Europe. High-income subregions all averaged more than 14 per 100000 people, whereas all low-income subregions, representing 2·2 billion people, had fewer than two theatres per 100 000. Pulse oximetry data from 54 countries suggested that around 77 700 (63 195–95 533) theatres worldwide (19·2% [15·2–23·9]) were not equipped with pulse oximeters.

Obviously, making a pulse oximetry machine available is not a perfect measure of the capacity to conduct safe surgery (interestingly, it turns out one can even purchase such machines on Amazon should one ever desire one).  Surgery is complicated.  Not only to you need some basic machines, but you also need a surgeon, anesthesia, a sterile environment, functioning equipment, a reliable blood supply and other items.  But if basic equipment is not there, it suggests that the rest is also lacking.  This study highlights how challenging, and different, addressing this health priority will be relative to simpler health interventions.

Photo Credit: Alin S/Flickr
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2 Responses to “A new metric of surgical capacity”

  1. Brian Hanley says:

    Hmmm. From my experience in developing world settings, I think this metric is very poor.

    Consider how long modern surgery has been around versus the deployment of pulse oximetry starting in 1982-83. Should we deduce then, that all surgery prior to that was poor or that capacity was low?

    Whether there is availability of surgery, or a good outcome is dependent on far more important things than this.

    I would choose several steps. At the foundation, I would choose training/education. Nothing substitutes for that. And I have to say, if I was to choose between a modern surgeon from Harvard and one of those old school Russian surgeons trained in field medicine, I'd go for the latter every time in a primitive situation. They learn to make do, crack their own scalpels out of glass, use herbs from the area, etc.

    For equipment, the most basic would be availability and use of sterilization equipment. A step past that, availability and use of good quality scalpels, saws, etc. A step above that, availability and use of pre-packaged, sterile needles, IV lines and bags/bottles. A step above that, availability of modern anesthetics. (Field anesthesia can be decent with things like heroin or opium, and it is common some places.) A step above that, availability of electrical power.

    Then there is availability of antibiotics, prepackaged dressings, microscopes, microtome equipment for pathology, diagnostic tests. The list could go on and I am, perhaps, belaboring the point overmuch.

  2. Anonymous says:

    I agree.

    It's interesting how papers like this attract more attention compared with programs that actually target what the underlying problem entails.

    Take WHO's GIEESC, for example, (that stands for Global Initiative for Essential and Emergency Surgical Care) that, since 2005, has tried to bring together different Surgical Societies and Ministries of Health from different countries to concentrate their effort in solving this problem.

    To date, they have successfully instituted up to 40 different surgical training programs/education of local surgeons at the grassroots level.

    They have developed a 'checklist' to target the "availability and use of sterilization equipment", as Brian mentioned, the "availability and use of good quality scalpels, saws, etc…" and all the rest he mentions.

    They are planning to integrate this training course at the policy level in different low- and middle-income countries but since they lack funding, WHO is now cutting them off and curtailing their work, which I think will set back Global Surgery another 5-10 years.

    It seems strange to me that they're not getting the attention and support they deserve, while the rest of the world upholds a single datapoint that could potentially hold a continuum of confounding variables.

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