The global burden of surgical disease: past, present and future.

Abstract

The global burden of disease (GBD) study was the first, and remains the only, comprehensive attempt at quantifying disease burden worldwide. The initial GBD study in 1992 highlighted the burden of various diseases, and risk factors of disease, many of which remain poorly addressed. This study introduced a new metric, disability adjusted life years (DALYs), through which it became possible to calculate time lost through premature death and time lived with disability. Many of the disease groups identified in the GBD study (including malignancies and musculoskeletal disorders) are amenable to surgical correction and constitute a considerable proportion of the GBD. Revisions of the GBD study provide the international community with valuable data depicting trends in disease patterns from which health policy makers may base priority setting at both a national and an international level on public health issues, as well as informing future trends. Recently, considerable efforts have been made to define an internationally applicable standardised health metric to evaluate access to safe surgical care (incorporating disease burden and health system performance) in order to monitor trends and inform efforts in public health surveillance. Investment in improving disease monitoring and surveillance systems in lowand middle-income countries remains vital, as statistical undertakings in the developing world are inherently fraught. The limited inbuilt health infrastructure compromises capacity to collate adequate epidemiologic and vital statistics. Further regional descriptive epidemiology exploring the social determinants of health to improve the understanding of the heterogeneity in local perceptions of disease burden may also contribute to developing contextually appropriate measures to address local issues. Recent efforts to improve access to surgical care in lowand middle-income countries include the World Health Organization’s (WHO) Surgical Safety Checklist and the Global Initiative for Emergency and Essential Surgical Care Program. Despite compelling evidence of the benefit of surgical safety checklists in improving mortality and patient outcomes, a recent article by Urbach and colleagues suggested that implementation of the checklist in a Canadian hospital was not associated with a significant reduction in operative mortality or complications. Although it cannot be assumed that the institution of a checklist will inevitably facilitate an improvement in patient outcomes, hospitals in high-income countries are perhaps less likely to show improvements as they are likely to already have protocols in place to minimise adverse surgical events. In many resource constrained countries the effect of a checklist will likely bring about marked reductions in patient mortality and thus the findings to the contrary should be interpreted with due caution. With the growing evidence-base and increasing compliance with the checklist its use remains a vital component in the delivery of safe surgical care globally. At the 135th executive board meeting of the WHO, in May 2014, ‘Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage’ was discussed as an agenda item for the first time. This marks a significant milestone in the efforts of countless surgeons, healthcare professionals, non-governmental organisations, academics, students and civil society over the years in advocating for surgical care to be recognised as a global health priority. However, much remains to be done to ensure that a WHO resolution on this agenda item is passed. Furthermore, in order to ensure that current efforts to increase awareness of the need for improved surgical care in lowand middle-income countries bring about improvements in population health critical challenges such as gaps in surgical services, including strengthening the surgical workforce and health system infrastructure must be addressed. These challenges combined with garnering political commitment are crucial to sustained improvements in surgical care globally. There also exists a need to frame global surgery objectives within the wider landscape of global