In Africa, surgery may be thought of as the neglected stepchild of global public health. There are fewer physicians per population on this continent than on any other; surgeons are rarer still, and almost all of them work in the urban enclaves of what remains a rural region. The story is the same in the poorer parts of Asia and Latin America (with a few exceptions, such as Cuba). Although disease treatable by surgery remains a ranking killer of the world’s poor, major financers of public health have shown that they do not regard surgical disease as a priority even though, for example, more than 500,000 women die each year in childbirth; these deaths are largely attributable to an absence of surgical services and other means of stopping post-partum hemorrhage . Equally unattended, among the very poor, are motor-vehicle and farm accidents, peritonitis, long-bone fractures, and even blindness [2-4]. Cardiac disease, congenital or the sequela of infection, is a death sentence for most people—many of them children—so afflicted in the poorest parts of the world [5, 6]. In some settings, surveys reveal that surgical disease is among the top 15 causes of disability , and surgical conditions account for up to 15% of total disability adjusted life years (DALYs) lost worldwide .
If it is true that surgery is the neglected stepchild of global health, does it follow that there are no surgical services available in the poor world? The truth is even more unpleasant: within poor countries, surgical services are concentrated almost wholly in cities and reserved largely for those who can pay for them. In Haiti, for example, a community-based survey conducted in the 1980s suggested that rates of caesarian section in a large area of southern Haiti were close to zero; maternal mortality was pegged at 1,400 per 100,000 live births . Yet among the affluent of that same country, rates of caesarian section do not vary much from those registered in the United States. Careful scrutiny of local inequalities of risk and access to care reveals that in poor countries, even minor surgical pathologies are often transformed through time and inattention into lethal conditions. Congenital abnormalities such as cleft palate remain life-long afflictions rather than pediatric surgical disease. In addition to surgical abdomens, severe trauma (from road accidents more often than from intentional violence) and other potentially fatal pathologies remain a massive burden of untreated disease that weighs on the lives, and productivity, of the world’s bottom billion.
When we at the non-governmental organization Partners In Health (PIH) asked ourselves, in rural central Haiti, whether or not we would let ability to pay even the smallest fee determine who would have access to surgical care, we decided to approach surgical disease as we did AIDS or tuberculosis. Unless we waived fees, we would most certainly exclude some of the very people we had come to serve in the first place. We were not surprised when we became the region’s, then the country’s, de facto provider of last resort. The only way to decrease the caseload in our hospital would be to strengthen the area’s public hospitals and permit them to offer equivalent services, also as a public good for public health . It is noteworthy that the only significant advance in the effort to make surgical care something other than a commodity has been with respect to caesarian sections. In August 2007, the district health commissioner for central Haiti, faced with staggering local inequalities in maternal mortality, announced that all prenatal care and emergency obstetrical services would from then on be available free of charge to the patient.