"It is not news that the poor have worse access to hospital services like surgery. But the size of the population is a shock," said Atul Gawande, associate professor at Harvard School of Public Health and head of the World Health Organization (WHO) initiative, Safe Surgery Saves Lives.
Even though a substantial number of diseases worldwide require surgery, residents of higher-income regions undergo 75 percent of surgeries annually, versus the poorest third who account for only 4 percent, according to a 2010 Harvard University School of Public Health study.
Based on profiles of 769 hospitals in 92 countries, wealthier countries had 14 operating theatres per 100,000 people versus two in lower-income regions.
A separate February 2010 study of 132 health facilities in eight countries (Sri Lanka, Mongolia, Tanzania, Afghanistan, Sierra Leone, Liberia, The Gambia and São Tomé and Príncipe) revealed infrastructure to be just one of the "enormous shortfalls" in emergency surgical care.
"Are there staff to assist with surgery? Next, do they have the supplies and equipment necessary to undertake the procedures? . Lastly, do the personnel have the knowledge and capability to treat?" asked Adam Kushner, the study's co-author and founder of the New York City-based NGO, Surgeons OverSeas.
The study highlighted shortages in all those areas. No surveyed centres reported uninterrupted water or electricity (and therefore oxygen supply), with most reporting less than a 50 percent supply of all three.
For MDG 5 (improve maternal health), 44 percent of facilities offered Caesarean sections.
For MDG 6 (combating the spread of HIV/AIDS) 48 percent of the surveyed centres offered male circumcision, recommended by WHO to fight the spread of HIV.
W here are the surgeons?
Specialist surgeons and anaesthetists are scarce where they are most needed, for example, in sub-Saharan Africa, according to a 2010 medical survey published in Plos Medicine of eight district hospitals in Uganda, Mozambique and Tanzania.
In 2008, Uganda had 10 specialist surgeons and 350 anaesthetists for a population of more than 30 million.
In Mali, Mamby Keïta, a surgeon at the country's largest hospital, Gabriel Touré Hospital in the capital Bamako, told IRIN there were three paediatric surgeons nationwide in 2010 to serve an estimated 2.2 million under-five children (2008); four more are in training but not expected to graduate until 2012.
"We also need paediatric anaesthetists. The absence of such technicians limits how many paediatric surgeries we can do," said Keïta.
To help cover the shortage of local surgeons, there are international doctors serving short-term contracts; NGOs; visiting humanitarian projects such as Operation Smile or the faith-based NGO, Mercy Ships, a hospital at sea that docks for months at a time to offer medical procedures including surgery; or mid-level health workers and nurses.
Non-doctors carried out half of all surgical procedures in the centres surveyed in the Plos Medicine study. Kushner said it was critical to prepare all levels of health workers to carry out emergency surgical procedures - rather than foregoing surgical care.
|Surgery has been a neglected component of public health planning and this clearly needs to change|
The Global Initiative for Emergency and Essential Surgical Care, an international collaboration of health ministries launched in 2005 to boost emergency surgical care as a way to meet MDGs, is scheduled to be phased out.
"Surgery has been a neglected component of public health planning and this clearly needs to change," said safe surgery initiative director Gawande.
In addition, there is still a poor understanding of surgical needs and the cost of foregoing critical care, said Kushner, whose NGO is planning to conduct a study on the overall surgical needs of different communities, rather than focusing only on health facility usage.
"We cannot really understand needs of the population by solely looking at those who actually decide to seek care in hospitals, and survive to receive this care. Our assumption is that more. individuals are dying from a lack of surgical care, but do so before they arrive in hospitals."