Global surgery: defining an emerging global health field.

Global health is one of the defi ning issues of the 21st century, attracting unprecedented levels of interest and propelling health and disease from a biomedical process to a social, economic, political, and environmental concern. Surgery, however, has not been considered an integral component of global health and has remained largely absent from the discipline’s discourse. After much inattention, surgery is now gaining recognition as a legitimate component of global health. In January, 2014, Jim Kim, President of the World Bank, urged the global health community to challenge the injustice of global inequity in surgical care, stating that “surgery is an indivisible, indispensable part of health care and of progress towards universal health coverage”. However, defi ning a place for surgery within the current global health paradigm of disease-based care and issue-specifi c advocacy remains a challenge—surgery is not a distinct disease entity such as HIV/AIDS, nor does it target a specifi c demographic such as reproductive, maternal, neonatal, and child health. Rather, surgery plays a part in addressing a diverse set of cross-cutting health challenges within a health system and is crucial to the full attainment of global health goals. Individuals and groups committed to addressing global inequity in access to surgery and improving the status of surgical care within global health have started to come together under the umbrella of global surgery. Although the term global surgery has rapidly entered the vernacular, a defi nition has not been provided. Here, we discuss the importance of defi ning global surgery to advance its role as an indivisible component of global health and propose a working defi nition that can serve as a focal point around which both the surgical and wider global health community can unite. Increased awareness of the place for surgery within global health will benefi t not only the surgical community, but all those working to improve health outcomes, strengthen health systems, and reduce health inequities at a local and global scale. Common defi nitions in global health are central to the setting of objectives, priorities, and strategies, communication of goals and vision, and channelling of resources. They can also act as a rallying point, to unify diff erent actors and create strong community cohesion, which is key to generation of political priority. The nascent global surgery movement would do well to learn from global health’s mistakes. Failure to defi ne global health early in its own development allowed and even encouraged several, competing, and sometimes contradictory frames of reference to emerge. The confusion was damaging and created silos and factions among groups instead of cohesion and cooperation. Although global surgery has not been defi ned formally, defi nitions for various related terms including surgical care, surgical conditions, and surgical providers have been proposed (appendix). These defi nitions take a broad, inclusive approach to the defi nition of surgery, recognising that surgical care is usually delivered within multidisciplinary teams. Such care does not always involve an operation or procedure and can be delivered at primary care level and in the hospital setting. Underpinning the emergence of the term global surgery has been a desire to link surgical need with the overall global health agenda. To defi ne global surgery conceptually, the central tenets of global health therefore need to be incorporated. These tenets have themselves been the subject of much analysis and debate, but are broadly considered to include the global conceptualisation of health, the synthesis of population-based approaches with individual level clinical care, the central concept of equity in health, and the cross-sectoral, interdisciplinary approach to the understanding of ill health and its solutions. The term global in global health refers to health issues that are worldwide or universally present, that transcend national boundaries, and are supraterritorial—such as, for example, climate change. The key commonality is that global is used to refer to the scope of the problems not their physical location. So too for global surgery. In the absence of a clear defi nition, global surgery has been increasingly used to refer to surgery within geographical boundaries, and particularly within low-income and middle-income countries. A focus on these countries is appropriate because inequity is greatest in these regions. However, defi nition of the specialty as referring only to the problems of specifi c countries or regions would be incorrect. Concentration on the scope of the problems and the processes driving them rather than the geographical boundaries in which they are contained allows for greater insight into determinants and solutions. A global approach to surgery will mean a change in the way responsibility and accountability for surgical care are approached. Because the causes of inadequate or inequitable surgical care and the solutions are often interconnected or interdependent, the burden and responsibility for improving care is collective and needs to extend beyond sovereign borders. Identifi cation of successful strategies for increasing collective responsibility, action, and accountability at a global level, which are also locally grounded, will be crucial to meaningful progress in global surgery. The emergence of several transnational initiatives that address globally relevant issues in surgery such as patient safety, hospitalacquired infection, and international organ traffi cking are examples of strategies that have been conceived at a global level, developed on the basis of collective responsibility, and adopted within countries and local institutions. Published Online May 20, 2014 http://dx.doi.org/10.1016/ S0140-6736(14)60237-3