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The Lancet Commission on Global Surgery Global surgery 2030: Evidence and solutions for achieving health, welfare and economic development

2015; Elsevier BV; Volume: 157; Issue: 5 Linguagem: Inglês

10.1016/j.surg.2015.02.009

1532-7361

John G. Meara, Sarah Greenberg,

Diversity and Career in Medicine

The vision of the lancet commission on global surgery is universal access to safe, affordable, surgical and anaesthesia care when needed.1Meara JG, Leather A, Hagander L, Alkire BC, Alonso N, Ameh EA, et al. Global Surgery 2030: Evidence and Solutions for Achieving Health, Welfare and Economic Development. Lancet, in press.Google Scholar Five billion people, largely the poor, marginalized, and rural, face impossible hurdles and for all practical purposes are excluded from what often is life-saving or disability-averting treatment.2Raykar N, Alkire BC, Shrime MG, Weiser TG, Bickler SW, Rose J, et al. Global access to surgical care: a modeling exercise. The Lancet, in press.Google Scholar For many, it is simply lack of money; for others, it is the tyranny of distance and poor transportation infrastructure. For the remainder who can afford it and can travel the distance, they arrive to find a feeble health care system with too few surgeons or anesthetists, no medications, no oxygen, and no blood for needed transfusion. In an era in which we discuss the dawn of personalized medicine and genetic engineering with frequency and familiarity, how can we allow more than half the world's population to live in a "health care time warp," trapping them centuries in the past? In short, the reasons are inaccurate assumptions, competing priorities, and a lack of resolve. For years, the public health community assumed that surgery was too costly and too complex, a luxury to be afforded only by the wealthy elite. This belief led the public health intelligentsia to concentrate on ostensibly more cost-effective interventions like vaccines and treatments for infectious diseases, all of which are necessary but in reality no more cost-effective than surgery.3Chao T.E. Sharma K. Mandigo M. et al.Cost-effectiveness of surgery and its policy implications for global health: a systematic review and analysis.Lancet Global Health. 2014; 2: e334-e345Abstract Full Text Full Text PDF PubMed Scopus (237) Google Scholar To add to these false assumptions and competing priorities, the house of surgery and the anesthesia community lacked a cohesive resolve to reverse the prevailing winds of surgical marginalization. And to be clear, surgical marginalization has a cost that is only projected to increase. With changing epidemiologic trends, the burden of noncommunicable diseases and injuries is increasing at an ominous pace,4Global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet, in press.Google Scholar making integration of surgery and anesthesia care critical to achieving the newly evolving Sustainable Development Goals and the commitments to Universal Health Coverage. Without immediate attention and scale up, absence of surgical care will not only continue to result in preventable death and disability for millions, but it is also estimated to decrease the gross domestic product of low- and middle-income countries by as much at 2.0% by 2030.5Alkire BC, Shrime MG, Dare AJ, Vincent JR, Meara JG. The global economic consequences of selected surgical diseases. Lancet Global Health, in press.Google Scholar This outcome will be crippling for those fragile economies struggling to emerge from poverty and instability. Times have changed, and in January 2014, the words of the president of the World Bank, Jim Kim, to the first assembly of the Lancet Commission on Global Surgery symbolized a tipping point. He reformatted the surgical landscape when he stated that, "surgery is an indivisible, indispensable part of health care."6Kim JY. Opening address at the inaugural meeting of The Lancet Commission on Global Surgery. First Meeting of The Lancet Commission on Global Surgery; 2014 January 17 2014; Boston, MA, USA; 2014.Google Scholar And he then went a step further to say "I urge you to challenge this injustice and to build a shared vision and strategy for global equity in essential surgical care."6Kim JY. Opening address at the inaugural meeting of The Lancet Commission on Global Surgery. First Meeting of The Lancet Commission on Global Surgery; 2014 January 17 2014; Boston, MA, USA; 2014.Google Scholar Fortunately, Dr Kim's words landed on fertile ground prepared by the hard work and dedication of numerous individuals and groups, such as the Bellagio Essential Surgery Group, the 2nd and 3rd editions of Disease Control Priorities, the Global Initiative for Emergency and Essential Surgical Care by the World Health Organization, and thousands of frontline providers who fight daily to save their patients despite a lack of the most basic resources. Without these steadfast efforts, Dr Kim's words might have fallen undetected on fallow ground. The surgical "fields" had been tilled, and 2014 and 2015 saw the unfolding of several worldwide events that complemented and catalyzed the work of the Lancet Commission. A World Health Assembly Resolution on strengthening the surgical system and essential surgery gained momentum via multi-country support at the World Health Organization led by Dr. Emmanuel Makasa from Zambia. On January 30, 2015, EB136/27 was passed by the World Health Organization Executive Board and will go for final vote at the May World Health Assembly meeting.7Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Report by the Secretariat. Executive Board, 136th session: World Health Organization. http://apps.who.int/gb/ebwha/pdf_files/EB136/B136_27-en.pdf.Google Scholar At the same time, 2015 marked a transition from the more condition-specific Millennium Development Goals to a collection of health and development targets (Sustainable Development Goals) aimed broadly at decreasing poverty, and increasing universal health coverage and equity. On April 27 and 28, London hosted the initial launch of the Lancet Commission on Global Surgery in collaboration with the Royal Society of Medicine. The second launch followed shortly thereafter in Boston on May 6 and 7. These launches represented the culmination of more than 2 years of work by hundreds of people in 111 countries, 4 international meetings, and multiple regional events—a broad, purposeful and critical outreach effort. The launches in London and Boston were just that, ie, the beginning of a campaign of education and advocacy intended to highlight the pivotal role of surgical care in the strengthening of health systems. The formal Commission report, 32,000 words of synthesis, analysis, recommendations, and indicators, is only one part of the initial Commission product. A dozen, open-access, business-style teaching cases were published to provide an educational framework focused on topics in global surgery. In addition, 61 abstracts were presented at the London launch, and numerous full-length articles are to be published in The Lancet, The Lancet Global Health, World Journal of Surgery, British Journal of Surgery, and SURGERY. This is the greatest volume of academic content addressing global surgery published in a synchronized fashion in collaboration with 5 independent journals ever seen in the surgical community. SURGERY will devote 3 months—May, June, and July—to articles linked to the Lancet Commission on Global Surgery. By presenting work from all over the world, this commitment by SURGERY highlights the importance of international collaboration in combating "surgical marginalization" in public health and supports the themes and vision of the Commission. This approach represents a bold step forward in a new era with surgery as an equal partner in the health care prevention, treatment, and cure. No longer a neglected and distant relative, we must transition from calling out problems to defining solutions. And we must be clear in our message. This is not a scramble for scarce resources; rather, it is a cooperative movement based on accompaniment and equity, in which transparency and accountability must prevail around the flow of investments and funding, the workforce, and ultimately the outcomes that matter most to patients. So if this is our first step, how do we maintain forward progress? SURGERY can help as it is doing in the May, June, and July issues as well as its other initiatives to highlight the work in global surgery through an academic lens. To be successful, however, surgeons, obstetricians, and anesthesiologists must engage in training, education, research, and advocacy WITH our global partners in resource-poor regions through true accompaniment, global collaboration, and an emphasis on systems, not silos. Only in this way will we be able to achieve health, welfare, and economic development for all.