Book review: Operation Health—Surgical Care in the Developing World

The Lancet Commission on Global Surgery recently reported that “5 billion people do not have access to safe, affordable surgical and anesthesia care when needed. Access is worst in low-income and lower-middle-income countries, where nine of ten people cannot access basic surgical care.”
This timely book, edited by Adam L. Kushner, MD, MPH who is on the faculty of both Columbia University and the Johns Hopkins and is a director of the Society of International Humanitarian Surgeons/Surgeons OverSeas (SOS), explains many of the important issues.

In 100 pages and 11 chapters, the assembled international contributors cover such diverse topics as assessing the needs of low-and middle-income countries (LMICs) worldwide, HIV, trauma, women’s health, and process improvement.

The chapters are brief, but packed with useful information most of which is based on research carried out in the field.

Each chapter is introduced by a personal vignette that highlights the importance of the work that Dr. Kushner and his colleagues have been doing.

For someone (like me) with minimal knowledge of the problems confronting those who must care for patients in LMICs, the book is a real eye-opener.

Some of the statistics about the number of surgeons per capita in LMICs are staggering. Countries such as Malawi and Mozambique have 0.1 and 0.2 surgeons per 100,000 population respectively. In the United States, the number is 43.

Anesthesia services are almost as deficient. For example, the 25 million people of Ghana are served by only 15 anesthesiologists and 300 nurse anesthetists or 1.26 anesthesia providers per 100,000 people compared to 24 per 100,000 in the United States.

In Ethiopia where the cesarean section rate is 0.6%, maternal mortality occurs in 667 per 100,000 women, and there are over 140,000 women with obstetrical fistulas.

A surgeon in Mongolia has been instrumental in developing minimally invasive surgery in her country. Although it may seem counterintuitive, minimally invasive surgery in LMICs is cost-effective because it eliminates the need for lengthy hospitalizations and enables poor patients to return to work much more quickly than an open procedure.

The book contains many more interesting facts along with definitive plans for improving access to surgery for citizens of LMICs. Solutions are not simple because in addition to personnel shortages, there are issues with affordability of care, lack of public transportation, and even properly maintained roads, to name a few.

While we worry that our competing hospital in the next town has bought its third da Vinci robot, people in LMICs would settle for an uninterrupted supply of electricity.

We have a long way to go before routine surgery is available in many countries. Some people are working to make it happen, and you can read about them in Operation Health.

Disclosure: I received a free copy of the book.