Date Published: June 3, 2008
Publisher: Public Library of Science
Author(s): Doruk Ozgediz, Robert Riviello
Abstract: Doruk Ozgediz and Robert Riviello discuss the burden of premature death and disability and the economic burden of surgical conditions in Africa.
Partial Text: Currently in sub-Saharan Africa, most patients with surgical problems that are routinely treatable in high-income countries never reach a health facility, or are treated at a facility with inadequate human or physical resources. These conditions lead to premature death or physical disability with a significant economic burden. Meanwhile, the last decade has seen the emergence of numerous “neglected tropical disease” (NTD) initiatives in global public health. As surgeons working with clinicians in sub-Saharan Africa, the momentum for NTDs causes us to ask: Shouldn’t surgical conditions also be considered “neglected”?
Variably defined [1,2], NTDs are primarily parasitic and bacterial infectious diseases—excluding the “big three” infections (HIV, tuberculosis, and malaria)—that affect the world’s rural poor in low-income countries (LICs) and can be cheaply addressed [1,2]. Despite their significant, primarily chronic disease burden, they are sidelined as “other diseases” in the Millennium Development Goals.
Injuries account for the greatest burden of surgical disease worldwide (63 million DALYs) and in Africa (10 million DALYs), and are followed by obstetric complications (4 million DALYs in Africa), malignancies, congenital anomalies, and perinatal conditions (approximately 2 million DALYs each in Africa). As with NTDs, the burden of disease from injuries is disproportionately borne in LICs, where 90% of injury deaths occur. In men aged 15–44, the predominant economically active segment of the population, only HIV takes more lives than road traffic crashes, and for every death, dozens are left with temporary or permanent disabilities [8,9]. High-income countries experience 1.7 deaths/10,000 vehicles compared to more than 50/10,000 vehicles in Africa . In African children over five, injuries claim more lives than HIV, tuberculosis, and malaria combined . Only one third of injured patients in Africa reach a health facility—and greatly delayed presentation is the rule rather than the exception.
The shortage of physicians and nurses in Africa has been well-documented: Africa bears nearly 25% of the global burden of disease with only 2% of the global health workforce . The neglect of training institutions as well as the “brain drain” of physicians and other health personnel to rich countries contributes to this imbalance. Policies to counteract the brain drain by limiting recruitment of nurses have been initiated; in addition, capacity-building of academic institutions has also been successful in retaining national health care workers in some countries [20,21].
Many LICs have a double burden of infectious and noncommunicable diseases. Proponents of vertical infectious disease initiatives maintain that these programs will strengthen health systems overall. From a clinical perspective, however, there may be a widening gap between generous infectious disease programs supported by major donor organizations and basic essential health services. For example, of the 111 donor-supported health projects in Uganda totaling nearly US$300 million over the last two years, only two have partially supported regional hospital services . US$85/DALY is spent on HIV research compared to only US$0.50/DALY for injury research .
NTD initiatives have emphasized the lack of investment in research and drug development, partially due to poor incentives and market failures in the pharmaceutical industry . As a result of these failures, drug development for NTDs has stalled while “blockbuster” drugs have been developed for diseases that preferentially affect high-income countries. Similarly, “blockbuster” devices and technologies have been developed for surgical conditions in high-income countries, led by advances in laparoscopy, arthroscopy, and other techniques.
Surgical conditions share a number of characteristics with NTDs. Both account for a significant disease burden, disproportionately borne in Africa, and are relatively cost-effective to treat. Nonetheless, both have been neglected as priority health interventions. The burden of injuries and obstetric complications are particularly significant. Surgical care, which depends on adequately trained personnel and infrastructure, may be more difficult to deliver than medical treatments for NTDs. Nonetheless, lessons from NTD initiatives may improve access to surgical care through donation programs, nonprofit ventures, advocacy, and development of incentives to reduce the price and improve the availability of essential equipment and supplies. Perhaps most importantly, proponents for NTDs cite the basic human right to health and the potential for poverty reduction achievable through these programs . This human right to health includes access to essential surgical care. Patients with untreated surgical conditions, as well as the local clinicians struggling to care for them, must gain greater recognition by the global public health community.