Doruk Ozgediz

Disparities in global pediatric surgery are highlighted in Uganda, where 4 pediatric surgeons serve over 20 million children. In 2015, the nongovernmental organization (NGO) ARCHIE Global Surgery opened the first pediatric operating room in the country, combining efforts with local pediatric surgeons to expand neonatal and pediatric surgical capacity. This study examined the cost-effectiveness of constructing and maintaining the pediatric surgical unit from the NGO perspective.

Introduction: Colorectal polyps usually present with rectal bleeding and are associated with increased risk of colorectal carcinoma. Evaluation and management in resource-poor areas present unique challenges. Presentation of case This 15 year-old boy presented with 9 years of painless rectal bleeding and 2 years of a prolapsing rectal mass after passing stool. He had 3 nephews with similar symptoms. On clinical assessment and initial exam under anesthesia, an impression of a polyposis syndrome was made and a biopsy taken from the mass that revealed inflammatory polyps with no dysplasia. He was identified during a pediatric surgical outreach to a rural area with no endoscopy, limited surgical services, and no genetic testing available, even at a tertiary center. He subsequently had a three-stage proctocolectomy and ileal pouch anal anastomosis with good outcome after referral to a tertiary care center. The surgical specimen showed many polyps scattered through the colon. Discussion: In the absence of endoscopic surveillance and diagnostic services including advanced pathology and genetic testing, colorectal polyposis syndromes are a significant challenge if encountered in these settings. Reports from similar settings have not included this surgical treatment, often opting for partial colectomy. Nonetheless, good outcomes can be achieved even given these constraints. The case also illustrates the complexity of untreated chronic pediatric surgical disease in rural resource-poor areas with limited health care access. Conclusion: Polyposis syndromes in children present unique challenges in rural resource-poor settings. Good outcomes can be achieved with total proctocolectomy and ileal pouch anastomosis.

The global burden of disease (GBD) has been measured primarily through the use of the DALY metric. Using this approach, preliminary estimates were that 11% of the GBD is surgical. However, prior work has questioned specific aspects of the GBD methodology as well as its practicality. This paper refines other conceptual approaches based on met and unmet population need for services by considering incident and prevalent need as well as backlogs for treatment that can inform effective coverage of services. Some of these methods are tested using the example of surgical repair of cleft lip and palate. Measurement of disability incurred by delays in care may also be estimated through these approaches and has not previously been estimated through a validated model. These concepts may provide more practical information for individuals and organizations to advocate for scaling up surgical programs. While many surgical conditions are unique, as a single intervention can lead to cure, these concepts may also prove useful for non-surgical diseases. Further exploration of these approaches is merited in resource-limited settings.

Introduction: In recent years, surgical providers and advocates have engaged in a growing effort to establish metrics to estimate capacity for surgical services as well the burden of surgical diseases in resource‐limited settings. The burden of disease (BoD) studies have established the disability‐adjusted life year (DALY) as the primary metric to measure both disability and premature mortality. Nonetheless, DALY‐based approaches present methodological challenges, some of which are unique to surgical conditions, not fully addressed through the multiple iterations of the BoD studies, including the most recent study.Methods and Results: This paper examines these challenges in detail, including issues around age‐weighting and discounting, and estimates of disability‐weights for specific conditions. Surgical burden measurements of specific conditions, or through the assessment of hospital wards as platforms for service delivery, still have unresolved methodological hurdles. The 2010 BoD study addresses some of these issues, but many questions still remain. Other methods estimating surgical prevalence, backlogs in treatment, and disability incurred by delays in care may provide more practical approaches to disease burden that can be useful tools for clinicians and health advocates.Conclusions: These approaches warrant further exploration in LMICs and these debates require active engagement by surgical providers and advocates globally.

Surgical conditions account for a significant portion of the global burden of disease and have a substantial impact on public health in low‐ and middle‐income countries. This article reviews the significance of surgical conditions within the context of public health in these settings, and describes selected approaches to global surgery delivery in specific contexts. The discussion includes programs in global trauma care, surgical care in conflict and disaster, and anesthesia and perioperative care. Programs to develop surgical training in Botswana and pediatric surgery through international partnership are also described, with a final review of broader approaches to training for global surgical delivery. In each instance, innovative solutions, as well as lessons learned and reasons for program failure, are highlighted. Mt Sinai J Med 78:327–341, 2011. © 2011 Mount Sinai School of Medicine

Recently, surgical services have been gaining greater attention as an integral part of public health in low‐income countries due to the significant volume and burden of surgical conditions, growing evidence of the cost‐effectiveness of surgical intervention, and global disparities in surgical care. Nonetheless, there has been limited discussion of the key aspects of health policy related to surgical services in low‐income countries. Uganda, like other low‐income sub‐Saharan African countries, bears a heavy burden of surgical conditions with low surgical output in health facilities and significant unmet need for surgical care. To address this lack of adequate surgical services in Uganda, a diverse group of local stakeholders met in Kampala, Uganda, in May 2008 to develop a roadmap of key policy actions that would improve surgical services at the national level. The group identified a list of health policy priorities to improve surgical services in Uganda. The priorities were classified into three areas: (1) human resources, (2) health systems, and (3) research and advocacy. This article is a critical discussion of these health policy priorities with references to recent literature. This was the first such multidisciplinary meeting in Uganda with a focus on surgical services and its output may have relevance to health policy development in other low‐income countries planning to improve delivery of surgical services.

In a rights-based approach to health, the provision of essential surgical services is not a luxury, but a critical component of the "highest attainable standard of health." Yet while access to select basic health care interventions has increasingly been discussed as part of the human right to health, essential surgical services have generally not been part of this discussion. This is despite the substantial global burden of surgical conditions in low- and middle-income countries, extreme global disparities in access to surgical care, and the fact that relatively simple, cost-effective, and curative surgical procedures can avert disability and premature death from many life-threatening emergencies and other conditions. Many barriers, both supply and demand-related, such as constraints in human resources, infrastructure, and access to care, have limited the ability of health systems to deliver surgical services. In this paper, the authors share their experience - as a group of surgeons, anesthesiologists, emergency physicians, and public health experts working with colleagues in varied resource-constrained settings to provide basic surgical care - in addressing the challenge of realizing the right to surgery in resource-poor settings. We argue that essential surgical care should be included in the basic human right to health, and that the current emphasis on "vertical" disease-specific models of health service delivery should be broadened to include systems needed to provide surgical services. We outline the global burden of surgical conditions, discuss the public health importance of surgery, identify the most significant global disparities in access to surgical care, and provide economic arguments for surgical delivery.