We congratulate Ng-Kamstra et al for their excellent work in bringing surgery to the attention of the global health community, and acknowledging the shift in discourse that the Sustainable Development Goals has brought. However, the emphasis of this paper on high-income country (HIC) actors only reinforces the global health paradigm which plagued the MDG era. It does not consider emerging economies who will play a bigger role in global health as we approach 2030. We obviously applaud all efforts made to combat colonialism. However, we believe that assuming low and middle-income countries (LMIC) to not be ‘major actors’ is antithetical to this pursuit. It is false to assume that majority of influence on and investment in health systems in LMICs will be from Western powers supported by HIC trainees and surgical colleges.
There are several reasons we believe this to be misguided. Firstly, for many developing countries, aid from foreign nations is making up a decreasing part of their budget. The majority of spending in low- and middle-income countries (LMICs) is direct government expenditure supported by taxes. Donor money makes up just 14.8% of the health budget in Kenya, and much less so in countries like Morocco. Much of the prioritisation of surgical care must be led by the LMIC citizens, health workers, policy makers and business leaders, and any call to arms must be targeted as such!
We are also concerned with the persistent use of ‘colonial...
We congratulate Ng-Kamstra et al for their excellent work in bringing surgery to the attention of the global health community, and acknowledging the shift in discourse that the Sustainable Development Goals has brought. However, the emphasis of this paper on high-income country (HIC) actors only reinforces the global health paradigm which plagued the MDG era. It does not consider emerging economies who will play a bigger role in global health as we approach 2030. We obviously applaud all efforts made to combat colonialism. However, we believe that assuming low and middle-income countries (LMIC) to not be ‘major actors’ is antithetical to this pursuit. It is false to assume that majority of influence on and investment in health systems in LMICs will be from Western powers supported by HIC trainees and surgical colleges.
There are several reasons we believe this to be misguided. Firstly, for many developing countries, aid from foreign nations is making up a decreasing part of their budget. The majority of spending in low- and middle-income countries (LMICs) is direct government expenditure supported by taxes. Donor money makes up just 14.8% of the health budget in Kenya, and much less so in countries like Morocco. Much of the prioritisation of surgical care must be led by the LMIC citizens, health workers, policy makers and business leaders, and any call to arms must be targeted as such!
We are also concerned with the persistent use of ‘colonialism’ throughout this roadmap. Admittedly, this language is emotive in the context of historic and current relationships between some LMICs and Europe. However, it is not a concept universally understood or experienced by all LMICs globally. It further feeds into the narrative that all people in LMICs are subalterns, subject to decisions and control by Western nations. We ask the authors to be mindful of surgical imperialism, which assumes answers to problems of surgical delivery are held by Western academics and not by those who work in LMICs.
Whilst we are supportive of a call to arms for actors in HIC to work in collaboration with those from other settings, as budding surgeons of the future and an international coalition of students, we are disappointed by the representation of the papers authors; 75% from the USA, and just 12% from LMICs. Whilst HIC actors have an important and continuing role in the delivery of surgical care to the world’s most vulnerable, it is those of us in LMICs who will bear the brunt of this task and ought to be better represented and empowered to dictate the future of our health systems.
1. http://www.smartglobalhealth.org/pages/kenya-mission/kenya-health
http://blogs.worldbank.org/africacan/three-myths-about-aid-to-kenya
As the authors of Global Surgery 2030: a roadmap for high country actors eloquently summarise, 2015 was a pivotal year for global surgery, with four important events being the landmarks of success and promise (1):
(1) The Lancet Commission for Global Surgery (LCoGS) (2)
(2) The Essential Surgery volume of the Third Edition of Disease Control Priorities (DCP-3) identifying 44 surgical procedures deemed essential for public health (3)
(3) A World Health Organisation resolution on strengthening emergency and essential surgical care, approved by 194 member states during the 68th World Health Assembly (4)
(4) The launch of the G4 Alliance (5).
The sobering figure that an estimated 5 billion people have no access to safe surgery or anaesthetic care has galvanised the international community in response. Co-authors Ng-Kamstra and Greenberg, with their 39 other fellow authors, describe the discussions at the Boston launch of the LCoGS on 6th May 2015. They also provide a unified call for each cadre of high income country actors and include guidance for colleges and academic medical centres, trainees and training programmes, academia, funders, industry and finally the press and advocacy groups.
The US launch was preceded by the UK launch of the LCoGS on 27th April 2016, where, there was palpable enthusiasm in the room, most noticeably from the trainee body. Similar to other anaesthetic, obstetric and surgical trainees in many other h...
As the authors of Global Surgery 2030: a roadmap for high country actors eloquently summarise, 2015 was a pivotal year for global surgery, with four important events being the landmarks of success and promise (1):
(1) The Lancet Commission for Global Surgery (LCoGS) (2)
(2) The Essential Surgery volume of the Third Edition of Disease Control Priorities (DCP-3) identifying 44 surgical procedures deemed essential for public health (3)
(3) A World Health Organisation resolution on strengthening emergency and essential surgical care, approved by 194 member states during the 68th World Health Assembly (4)
(4) The launch of the G4 Alliance (5).
The sobering figure that an estimated 5 billion people have no access to safe surgery or anaesthetic care has galvanised the international community in response. Co-authors Ng-Kamstra and Greenberg, with their 39 other fellow authors, describe the discussions at the Boston launch of the LCoGS on 6th May 2015. They also provide a unified call for each cadre of high income country actors and include guidance for colleges and academic medical centres, trainees and training programmes, academia, funders, industry and finally the press and advocacy groups.
The US launch was preceded by the UK launch of the LCoGS on 27th April 2016, where, there was palpable enthusiasm in the room, most noticeably from the trainee body. Similar to other anaesthetic, obstetric and surgical trainees in many other high income countries we recognise that the opportunities to contribute in low and middle income country (LMIC) settings are heterogeneous, ad hoc and largely self-directed. Currently, higher surgical training in the UK has no accredited global surgical programme or fellowship. Time spent undertaking clinical, research or health systems strengthening work in a non-UK setting do not formally count towards completion of training.
There is no body of literature detailing the UK trainee experience, needs or barriers to contribution to global surgery. Reports from Canada and the US, where established programmes exist, suggest that both technical and non-technical skills can be acquired through global surgical experience and represent an advantage to their home healthcare system. (6) With the current strains on our National Health Service, we believe there is potential to benefit from motivated, inspired and well-rounded healthcare workers in LMICs when we engage in the spirit of co-development.
We surveyed 38 trainee members of the Global Anaesthesia Surgical and Obstetric Collaboration (GASOC) and Association of Surgeons of Great Britain and Ireland (ASGBI) (31 surgical, 4 obstetric and 3 anaesthetic) to establish UK opinion on the role of the Colleges, training programmes and academia. In addition to their medical school elective placement, all demonstrated commitment to global surgery, 100% having spent volitional time in LMICs. The most valuable opportunities available to a trainee through global surgical experience were reported as technical skills (96%), teaching (88%) and international policy (79%). Of those interested in combining research with a clinical placement (68%), the majority had an appetite for a formal research qualification.
The leading barriers to taking time out of formal training for global surgical experience were financial concerns (70%), lack of consultant mentorship (67%) and personal commitments (63%). Despite recognition of the considerable barriers, 88% said that they would select a training programme based on an opportunity in global surgery. The majority of respondents thought this should be just before or towards the end of specialty training, and with a clinical component of 6-36 months.
Currently there is good will and energy among trainees. UK trainees came together at the launch of the LCoGS in London and formed GASOC. The global health leaders of the future are advocating a coordinated, recognised network of opportunities, endorsed by our training Colleges, governmental, non-governmental organisations, and existing healthcare partnerships. We are committed to the roadmap suggested by Ng-Kastra et al. in the goal to improve access and quality of surgical care to individual patients all around the world (1).
Acknowledgements
We are grateful to GASOC and ASGBI International Development Committee for distributing the survey.
1. Ng-Kamstra J, Greenberg S, Abdullah F et al. Global Surgery 2030: a roadmap for high income countries. BMJ Glob Health. 2016;1:e000011.
2. Meara J, Leather A, Hargander L et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
3. Disease Control Priorities, Third Edition (Volume 1): Essential Surgery. 3rd ed. Debas HT, Donkor P, Gawande A, Jamison DT, Kruk M and Mock C, editors. World Bank Publishing: 2015.
4. Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage. Resolution A68/31 at the 68th World Health Assembly: 2015 Mar 20. Available athttp://www.apps.who.int/GB/ebwha/pdf_files/WHA68/A68_31-en.pdf (accessed on 30/05/2016).
5. http://www.theg4alliance.org (accessed on 30/05/2016).
6. Drain PK HK, Skeff KM, Hall TL, Gardner P. Global health training and international clinical rotations during residency: current status, needs and opportunities. Acad Med. 2009;84(3):320-5.
I read the article “Global Surgery 2030: a roadmap for high income country actors” with a mix of encouragement and disappointment. It is truly encouraging to see the publicity that this vitally important topic is garnering and that the message has been embraced by prominent journals. However, it was disappointing to see that the authors have not entirely embraced their own message.
It should be appreciated that the term "surgery" refers to a multidisciplinary endeavor that includes surgeons, anaesthetists, nurses, and others. The current conceptualization is that perioperative patient care is a team effort by equals rather than a ship of lowly seamen lead by an intrepid captain. The authors allude quite often to the multidisciplinary aspect while at the same time stating "Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it". Surely, the leadership and articulating the vision should be collaborative and should fall to whoever on the team is best able to deal with the specific issue. It was also further disconcerting to see that academic pursuit in LMICs is the exclusive domain of surgeons “Academia: support the conduct of research by surgeons in LMICs”. In order to succeed, the evaluation of care and the generation of new knowledge must be the role of all who provide perioperative care.
The nuanced di...
I read the article “Global Surgery 2030: a roadmap for high income country actors” with a mix of encouragement and disappointment. It is truly encouraging to see the publicity that this vitally important topic is garnering and that the message has been embraced by prominent journals. However, it was disappointing to see that the authors have not entirely embraced their own message.
It should be appreciated that the term "surgery" refers to a multidisciplinary endeavor that includes surgeons, anaesthetists, nurses, and others. The current conceptualization is that perioperative patient care is a team effort by equals rather than a ship of lowly seamen lead by an intrepid captain. The authors allude quite often to the multidisciplinary aspect while at the same time stating "Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it". Surely, the leadership and articulating the vision should be collaborative and should fall to whoever on the team is best able to deal with the specific issue. It was also further disconcerting to see that academic pursuit in LMICs is the exclusive domain of surgeons “Academia: support the conduct of research by surgeons in LMICs”. In order to succeed, the evaluation of care and the generation of new knowledge must be the role of all who provide perioperative care.
The nuanced differences between multidisciplinary surgery and the solitary surgeon are not only of importance in relation to credibly building effective alliances. Those who control national, regional and local budgets do not understand the differences and view surgery and surgeon as the same. Stories are already emerging where health ministries have cut funding to anaesthesia and nursing so as to fund the training of more surgeons. More surgeons unable to perform surgery because of the absence of the others needed for the team is not a goal we should aspire to. It behooves all of us in this enterprise to speak carefully, accurately, and consistently.
References:
Ng-Kamstra JS et al. BMJ Global Health. Global Surgery 2030: a roadmap for high income country actors. DOI: 10.1136/bmjgh-2015-000011 Published 6 April 2016
To the Editor
The article by Iyer et al. depicted the huge gap between recommended and actual scenario in Indian maternity care.1 The authors correctly pointed out the concentration of case load in a few numbers of hospitals. The study also highlighted skewed allocation of health care resources and dominance of the private sector; two recognized obstacles for achieving universal health care in a developing country like India.
However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a mu...
To the Editor
The article by Iyer et al. depicted the huge gap between recommended and actual scenario in Indian maternity care.1 The authors correctly pointed out the concentration of case load in a few numbers of hospitals. The study also highlighted skewed allocation of health care resources and dominance of the private sector; two recognized obstacles for achieving universal health care in a developing country like India.
However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a must for being qualified as DP. Mere presence of a Sub-center, Primary Health Center or Community Health Center (three levels of health care facilities in India) does not ensure existence of a DP. In brief, the strategy stresses on presence functional health facilities, rather than increasing number of hospital buildings. Consideration of these facts would help the readers understand the challenges better.
References
1. Iyer V, Sidney K, Mehta R, et al. Availability and provision of emergency obstetric care under a public– private partnership in three districts of Gujarat, India: lessons for Universal Health Coverage. BMJ Global Health 2016;1:e000019. doi:10.1136/bmjgh-2015-000019
2. Government of India. Maternal and newborn health toolkit. Ministry of health and family welfare. New Delhi. 2013.
3. WHO, UNICEF, UNFPA and AMDD. Monitoring emergency obstetric care: a handbook. Geneva: World Health Organisation, 2009.
Mishra and colleagues1, discussed a fairly discouraging trend of smoking over decades in India. But in India, tobacco chewing is also associated with the risk of cancer among those who never smoked bidis or cigarettes.2 Smokeless tobacco products like Gutkha (crushed areca nut, tobacco) and pan masala (mixture of tobacco, essence and other ingredients) are available in attractive colorful small sachets for as low as half a rupee, and have become increasingly popular with aggressive marketing and advertisements.
In addition, many Indians smoke the much cheaper, unfiltered crude tobacco product called Bidi, which is made of 0.15-0.25g of sun-dried flaked tobacco rolled in a dried rectangular piece of Tendu or Temburni leaf (Diospyrosmelanoxylon) and a thread securing the roll. Bidis have lower tobacco content than cigarettes, but more nicotine, tar and carbon monoxide. Stick for stick, they are deadlier. Unregulated, Bidi is a major form of tobacco use, with a predicted sale of 1031 billion bidis in 2007.3
There are however two sides of the tobacco coin in India: One side allows for the production of tobacco in the country. In 2012, India was the 2nd largest producer of tobacco in the world.4 On the other side, there are increasing taxes on the sale of tobacco product, which is a way of generating revenue and restricting its use. Although it is thought that higher taxes would make cigarettes unaffordable to poor Indians, these taxes have had the effect of promoti...
Mishra and colleagues1, discussed a fairly discouraging trend of smoking over decades in India. But in India, tobacco chewing is also associated with the risk of cancer among those who never smoked bidis or cigarettes.2 Smokeless tobacco products like Gutkha (crushed areca nut, tobacco) and pan masala (mixture of tobacco, essence and other ingredients) are available in attractive colorful small sachets for as low as half a rupee, and have become increasingly popular with aggressive marketing and advertisements.
In addition, many Indians smoke the much cheaper, unfiltered crude tobacco product called Bidi, which is made of 0.15-0.25g of sun-dried flaked tobacco rolled in a dried rectangular piece of Tendu or Temburni leaf (Diospyrosmelanoxylon) and a thread securing the roll. Bidis have lower tobacco content than cigarettes, but more nicotine, tar and carbon monoxide. Stick for stick, they are deadlier. Unregulated, Bidi is a major form of tobacco use, with a predicted sale of 1031 billion bidis in 2007.3
There are however two sides of the tobacco coin in India: One side allows for the production of tobacco in the country. In 2012, India was the 2nd largest producer of tobacco in the world.4 On the other side, there are increasing taxes on the sale of tobacco product, which is a way of generating revenue and restricting its use. Although it is thought that higher taxes would make cigarettes unaffordable to poor Indians, these taxes have had the effect of promoting the use of the unregulated Bidi.5 On the one hand, India is leading in tobacco production, exporting tobacco to generate revenue. On the other hand, India is increasing tax on tobacco.
It remains to be seen how increasing taxes on tobacco production without curtailing and regulating its production would benefit public health in India.
References
1. Mishra S, Joseph RA, Gupta PC, et al. Trends in bidi and cigarette smoking in India from 1998 to 2015, by age, gender and education. BMJ Global Health 2016;1:e000005.doi:10.1136/bmjgh-2015-000005
2. Sapkota A, Gajalakshmi V, Jetly DH, Roychowdhury S, Dikshit RP et al. (2007) Smokeless tobacco and increased risk of hypopharyngeal and laryngeal cancers: a multicentric case-control study from India. Int J Cancer 121: 1793-1798
3. Shimkhada R, Peabody JW. Tobacco control in India. Bull World Health Organ. 2003;81:48–52.
4. Food and agriculture organization of the United Nations. FAO. [Last accessed on 2016 April 17]. available from: http://faostat.fao.org/site/339/default.aspx .
5. Kyaing NN, Islam MA, Sinha DN, Rinchen S. Social, economic and legal dimensions of tobacco and its control in South-East Asia region. Indian J Public Health. 2011;55(3):161-8.
We congratulate Ng-Kamstra et al for their excellent work in bringing surgery to the attention of the global health community, and acknowledging the shift in discourse that the Sustainable Development Goals has brought. However, the emphasis of this paper on high-income country (HIC) actors only reinforces the global health paradigm which plagued the MDG era. It does not consider emerging economies who will play a bigger role in global health as we approach 2030. We obviously applaud all efforts made to combat colonialism. However, we believe that assuming low and middle-income countries (LMIC) to not be ‘major actors’ is antithetical to this pursuit. It is false to assume that majority of influence on and investment in health systems in LMICs will be from Western powers supported by HIC trainees and surgical colleges.
Show MoreThere are several reasons we believe this to be misguided. Firstly, for many developing countries, aid from foreign nations is making up a decreasing part of their budget. The majority of spending in low- and middle-income countries (LMICs) is direct government expenditure supported by taxes. Donor money makes up just 14.8% of the health budget in Kenya, and much less so in countries like Morocco. Much of the prioritisation of surgical care must be led by the LMIC citizens, health workers, policy makers and business leaders, and any call to arms must be targeted as such!
We are also concerned with the persistent use of ‘colonial...
As the authors of Global Surgery 2030: a roadmap for high country actors eloquently summarise, 2015 was a pivotal year for global surgery, with four important events being the landmarks of success and promise (1):
Show More(1) The Lancet Commission for Global Surgery (LCoGS) (2)
(2) The Essential Surgery volume of the Third Edition of Disease Control Priorities (DCP-3) identifying 44 surgical procedures deemed essential for public health (3)
(3) A World Health Organisation resolution on strengthening emergency and essential surgical care, approved by 194 member states during the 68th World Health Assembly (4)
(4) The launch of the G4 Alliance (5).
The sobering figure that an estimated 5 billion people have no access to safe surgery or anaesthetic care has galvanised the international community in response. Co-authors Ng-Kamstra and Greenberg, with their 39 other fellow authors, describe the discussions at the Boston launch of the LCoGS on 6th May 2015. They also provide a unified call for each cadre of high income country actors and include guidance for colleges and academic medical centres, trainees and training programmes, academia, funders, industry and finally the press and advocacy groups.
The US launch was preceded by the UK launch of the LCoGS on 27th April 2016, where, there was palpable enthusiasm in the room, most noticeably from the trainee body. Similar to other anaesthetic, obstetric and surgical trainees in many other h...
I read the article “Global Surgery 2030: a roadmap for high income country actors” with a mix of encouragement and disappointment. It is truly encouraging to see the publicity that this vitally important topic is garnering and that the message has been embraced by prominent journals. However, it was disappointing to see that the authors have not entirely embraced their own message.
Show MoreIt should be appreciated that the term "surgery" refers to a multidisciplinary endeavor that includes surgeons, anaesthetists, nurses, and others. The current conceptualization is that perioperative patient care is a team effort by equals rather than a ship of lowly seamen lead by an intrepid captain. The authors allude quite often to the multidisciplinary aspect while at the same time stating "Academic global surgeons, therefore, have an opportunity to illustrate the evidence base for the expansion of surgical care and direct the global action plan to achieve it". Surely, the leadership and articulating the vision should be collaborative and should fall to whoever on the team is best able to deal with the specific issue. It was also further disconcerting to see that academic pursuit in LMICs is the exclusive domain of surgeons “Academia: support the conduct of research by surgeons in LMICs”. In order to succeed, the evaluation of care and the generation of new knowledge must be the role of all who provide perioperative care.
The nuanced di...
To the Editor
Show MoreThe article by Iyer et al. depicted the huge gap between recommended and actual scenario in Indian maternity care.1 The authors correctly pointed out the concentration of case load in a few numbers of hospitals. The study also highlighted skewed allocation of health care resources and dominance of the private sector; two recognized obstacles for achieving universal health care in a developing country like India.
However, had they adopted country-specific guidelines instead of UN criteria, they would have been able to reflect the scenario in synchronization with the national perspective. The guidelines, as envisaged under 12th Five Year Plan (FYP), recommend two comprehensive emergency obstetric care (CEmOC) centers and 18 basic emergency obstetric care (BEmOC) centers for a population of one million in our country, considering 70% deliveries in public sector.2 Although the required number of CEmOC centers matches the UN criteria, the national norm differs in term of number of BEmOC centers from the UN criteria.3
The strategy under 12th FYP laid down uniform protocol for proportional distribution of delivery case load across the country. With this purpose, it designated all facilities conducting more than three deliveries per month as Delivery Point (DP) and identified few potential DP in each district. However, the presence of a Newborn Care Corner (NBCC) equipped with a radiant warmer and other basic amenities required for a newborn is a mu...
Mishra and colleagues1, discussed a fairly discouraging trend of smoking over decades in India. But in India, tobacco chewing is also associated with the risk of cancer among those who never smoked bidis or cigarettes.2 Smokeless tobacco products like Gutkha (crushed areca nut, tobacco) and pan masala (mixture of tobacco, essence and other ingredients) are available in attractive colorful small sachets for as low as half a rupee, and have become increasingly popular with aggressive marketing and advertisements.
Show MoreIn addition, many Indians smoke the much cheaper, unfiltered crude tobacco product called Bidi, which is made of 0.15-0.25g of sun-dried flaked tobacco rolled in a dried rectangular piece of Tendu or Temburni leaf (Diospyrosmelanoxylon) and a thread securing the roll. Bidis have lower tobacco content than cigarettes, but more nicotine, tar and carbon monoxide. Stick for stick, they are deadlier. Unregulated, Bidi is a major form of tobacco use, with a predicted sale of 1031 billion bidis in 2007.3
There are however two sides of the tobacco coin in India: One side allows for the production of tobacco in the country. In 2012, India was the 2nd largest producer of tobacco in the world.4 On the other side, there are increasing taxes on the sale of tobacco product, which is a way of generating revenue and restricting its use. Although it is thought that higher taxes would make cigarettes unaffordable to poor Indians, these taxes have had the effect of promoti...
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