World Health Organisation

Lord Ribeiro Excerpts

Wednesday 2nd July 2014 Lords Chamber

Asked by

[Lord Ribeiro]

To ask Her Majesty’s Government whether they will support the strengthening of emergency and essential surgical care and anaesthesia by the World Health Organisation to reduce the global burden of disease.

[Lord Ribeiro (Con)]

My Lords, I thank the Leader for making the allowance for me to get in and start this debate. I shall open by quoting from a paper in Lancet Global Health in 2014 from the surgical departments of Massachusetts General Hospital, Boston Children’s Hospital and Stanford University, California. It states:

“Global health efforts, guided in part by the Millennium Development Goals (MDGs) have focused mainly on the prevention and treatment of malnutrition, obstetric disorders, and communicable diseases. With the exception of a few surgical procedures—eg, caesarean delivery and male circumcision”—

the latter because it reduces the transmission of communicable diseases—

“surgical interventions have been largely ignored”.

The purpose of this debate is to raise awareness of the value of surgery as a means of delivering effective public health.

In 2010, road traffic accidents accounted for 75.5 million disability-adjusted life years, or DALYs, up by 20 million since 1990. Cancer is on the increase, as are other non-communicable diseases, as life expectancies in developing countries increase with the reduction of HIV/AIDS and deaths from malaria and other infectious diseases. The perception of surgery as an expensive intervention may itself be a barrier to its acceptance as a means of reducing the global burden of disease. There is good evidence from Professor Haile Debas and others that surgical conditions, especially trauma and injury, obstructed labour and congenital anomalies such as club feet and cleft palate are all public health problems. Yet attitudes to surgery—that it is only affordable for the rich in developing countries and lower-income countries—mean that it does not appear on the public health radar for the poor.

Let me give some facts. I thank the Library for its excellent briefing documents, which I hope all noble Lords have received. There are 234 million surgical operations performed globally every year, but the poorest one-third of the world population receive 3.5% of all surgical operations. Approximately 2 billion people have no access to surgical facilities, and this is a global crisis. In high-volume countries—the haves—we have more than 14 operating rooms or theatres per 100,000 of population. In sub-Saharan Africa there are fewer than two operating rooms per 100,000 of population. Globally, 77,000 operating theatres have no pulse oximeters to diagnose hypoxia, or low oxygen levels, during surgery. Here I declare an interest as the patron of Lifebox, a charity which delivers pulse oximeters globally. In all, this amounts to more than 30 million operations worldwide without basic safe monitoring. It takes us back to the old days, when one felt the pulse and estimated the condition of the patient purely on feel.

In 2012 the noble Lord, Lord McColl, and I hosted a meeting of surgeons determined to bring these concerns to a wider audience. We and others cofounded an organisation called the International Collaboration for Essential Surgery, or ICES. The concept is not new and it has been debated for more than 40 years, but the problem is becoming acute in developing countries as more of them suffer a brain drain of their doctors and highly qualified nurses. The definition of essential surgery is the provision of basic intervention which will prevent premature death and long-term disability. Evidence suggests that there are 15 basic surgical interventions which will deal with approximately 80% of basic surgical need and the commonest urgent pathology in a community, particularly in rural areas where doctors are scarce.

Because of the loss of traditionally trained surgeons, who migrate to the private sector in cities, work for NGOs or emigrate to other countries, we need to train up a new cadre of non-physician clinicians, or NPCs. In 1963 Tanzania started to train NPCs, commonly known then as barefoot doctors, as the idea came from China. Malawi’s first medical school began by training clinical officers to carry out general surgery, obstetrical procedures and others in 1980. Similar programmes have developed in Niger, Zaire, Burkina Faso, Ethiopia, Senegal, Somalia and South Sudan. I believe that this paradigm shift is happening right across most of sub-Saharan Africa; it is just that the rest of the world needs to recognise it and catch up with what is happening. There are currently some 47 sub-Saharan countries using non-physician clinicians or clinical officers.

As chairman and vice-chairman of the All-Party Parliamentary Group on Global Health, the noble Lord, Lord Crisp, and I wrote to DfID, pointing out the benefits of surgery in the public health arena. We posed two simple questions. How will DfID raise the profile of essential surgery as a public health priority, and how will the department help to frame surgery as a crucial and affordable public health intervention? The response was both disappointing and bland and suggested to me that the department’s focus remained on communicable diseases and the well-being of mothers and children. I am not saying that that is not an important priority, but that appeared to be its continuing stance. However, let us contrast that with the way in which the Department of Health and the then Chief Medical Officer, Sir Liam Donaldson, promoted the surgical checklist as part of the patient safety agenda in developing countries. This is now a must-do exercise in all NHS hospitals in the UK, and is gaining traction in sub-Saharan African countries.

The World Health Organisation initiative is making a difference not only in this context in terms of patient safety but in other areas as well. The WHO pulse oximetry project, to which I referred earlier, run by Lifebox, is a case in point. Similarly, the WHO global initiative for emergency essential surgical care and guidance for essential trauma care is also something that is developing apace. I noticed the criticism of DfID by the House of Commons International Development Committee in March, when it accused DfID of,

“raiding bilateral development programmes in low income countries”,

to,

“support disasters in middle income countries”.

It noted that,

“expenditure on low-income countries is … significantly lower than in 2010-11”,

and suggested that,

“DFID staff spend less time writing the perfect business case and more”,

time on the ground.

The International Collaboration for Essential Surgery, or ICES, has produced a powerful film entitled “The Right to Heal”, which was shown here in Parliament. This film identifies seven conditions which cause the vast majority of preventable surgical deaths and disability. They are quite simple; they are hernia, club foot, cleft palate, injury, cataracts, appendicitis and obstructed labour—which inevitably, in very young girls with underdeveloped pelvises, can go on to cause urethral fistulae. Surgery can relieve the suffering from many of these common conditions and return people to normal lives.

Will the Government support the resolution on emergency care, agreed by the 67th World Health Assembly, attended by 42 countries, including the United Kingdom, to be submitted at the 2015 assembly meeting? Secondly, the post-2015 sustainable development goals present an opportunity for the Government and DfID to support the role of surgery as a public health measure. Will they commit to doing so? Thirdly, will DfID examine the extent to which global surgery represents a component of its programme and expertise? What assurances can DfID give that it will review the development goals in respect of surgery and anaesthesia post-2015, when the millennium development goals end? Finally, I hope that the Government will make strong representation after this debate at the 13th working group of the UN sustainable development goals on 14 to 18 July, as this is a member state.