Developing world surgery: no operating theatres and no basic anaesthetic equipment
There are few surgeons who are as passionate as Atul Gawande about improving the desperate state of surgery in the poorest parts of the world. I met him a few years back at the launch of his bestselling book, “Complications”. He is a surgeon, academic, author, public health guru and heads Safe Surgery Saves Lives, a WHO group, formed to improve patient safety within surgical specialities. You cannot help but be impressed by the simplicity and the far-reaching consequences of research coming from the group. For example, a 19-point surgical checklist was introduced in eight hospitals in eight cities (Toronto, Canada; New Delhi, India; Amman, Jordan; Auckland, New Zealand; Manila, Philippines; Ifakara, Tanzania; London, England; and Seattle, WA) for 1 year. Use of the checklist reduced death rate from 1.5% to 0.8% and reduced complications occurring in hospital from 11% to 7%.
The Lancet Online First includes the latest study from Gawande’s group. Apparently, 11% of the world's disability-adjusted life years (a measure of the disability caused by diseases) are due to diseases that are often treated with surgery, whether coronary artery bypass graft surgery in coronary heart disease, carotid surgery in the setting of stroke, cancer surgery, or trauma surgery following road traffic accidents. There are huge global inequalities in terms of the operations performed. Out of 234 million surgical procedures done every year, the richest third of the world’s population has three-quarters of the operations, whereas the poorest third has only 4%. The latest study looks at how much of that inequality is due to two integral parts of surgery. One is the operating theatre, and the other is pulse oximetry, the simple process by which a patient’s blood oxygen levels are monitored during an operation. The study used WHO data from 769 hospitals in 92 countries. Importantly there were no differences in patients, health systems or wealth between countries that did have data about operating theatres and pulse oximetry and those which did not. Therefore, these factors are unlikely to be confounders.
The results make sombre reading. Rich countries like the UK had at least 14 operating theatres per 100 000 people, while all poor regions of the world (accounting for more than 2 billion people, or a third of the world’s population) had fewer than two operating theatres per 100 000 people. This is in spite of having more surgically treated diseases per head than do rich countries. As the authors state, “People in such regions are effectively without access to surgical care”. The fact that over half of operating theatres in sub-Saharan Africa did not have the facility to measure oxygen levels and therefore could not monitor a patient’s breathing during anaesthetic is horrifying and is probably the tip of the iceberg in terms of lack of other essential surgical and anaesthetic equipment. Whilst showing these inequalities does not solve them, it does the vital job of highlighting where global health initiatives need to focus.