Surgical Burden of Disease

Posted on | June 24, 2008 | 1 Comment

Thinking strategically about health in a connected world

Two weeks ago I participated in a conference in Norfolk, Virginia in a session with Dr. Selwyn Rogers, Chief of the Trauma Division at Harvard’s Brigham and Women’s Hospital and Director of the Center for Surgery and Public Health for Partners Health Care. Selwyn’s research interest is assessing clinical outcomes, characterizing outcomes from surgical procedures and examining variations in outcomes of different patient populations. His work has focused on populations at risk in both the developing and developed world. We were together to discuss the surgical burden of disease and the varied costs to individuals, families and societies as a result of unmet or under met surgical needs.

In the interest of full disclosure, the meeting we were participating in was the Annual Physician Training Program of Operation Smile, an organization run by my older brother Bill, and his wife Kathy. Their organization has served the surgical needs of 115,000 children with unrepaired cleft palates over the past 26 years around the world. One hundred or so health professionals from 28 developing nations were attending the two-week program, a combination of operative experiences at multiple academic institutions and didactic classes.

What made it interesting to me was how far we have come in the past 26 years. When they began, there was a great deal of debate within the public health community around priorities. Specifically, should we be bothering with surgical relief efforts in the developing world when the basic infrastructure needs — clean water, sanitation, stable food supply, protection from communicable diseases — are clearly not secure. There was much criticism about mission approaches, that brought relief, but were short lived, and seemed to accent the divide between the developing and developed world rather then bridge it. There was a heavy focus on medical miracles, managing complexity and assuring quality in some difficult settings.

The discussion these days is quite different. First, our notion of health throughout the world today involves reaching your full human potential rather then simply conquering a disease, disability, deficit or injury. We have begun to think about the impact and burden of disease not only in terms of a single individual, but in total — including impact on family, village, community and society; effect on financial, human and social capital; and impact on integrated political, economic, social and medical systems. We are much less hierarchical in our efforts to be helpful, whether at home or abroad. There is general recognition that big problems, to be resolved require cross-sector cooperation, including government, NGO’s, Academics, Corporations, and the people themselves. In fact, today, paternalism is rapidly giving way to partnerships and mutual decision making, and team approaches increasingly are viewed as more appropriate and effective then are individual heroics. Finally, we are less inclined to place the responsibility for managing “burden of disease,” a termed coined by Gro Brundtland at the WHO some 10 years ago, as the responsibility of one branch of Medicine, namely Public Health. Increasingly the people and all of the people caring for the people (in many different disciplines) have accepted that inequities, whether in our own backyard or across the ocean, are a combined failure, and that we all have a role in assuring just solutions.

Ours is an increasingly interdependent, small, fragile and transparent planet. Health is a right, and maintaining health a personal responsibility. And if you’re a caregiver, you are called upon to cooperate with others, to make a difference, to be wise and conscientious – to care. So Selwyn and I were there to discuss these issues. What was so interesting is that our audience was a multi-disciplinary group of doctors, nurses, dentists and other professional caregivers from 28 developing nations, but there was no divide – no we/them, no teacher/pupil, no developing/developed – just a group of people trying to share ideas and solutions. There were no arguments over priorities, no medical versus surgical, just the insight that if a village were forced to accept the failure of a child with a cleft left untreated, this failure would infect the potential not only of that child, but also of the family, friends and entire village. There was no sense of artificial geographic barriers. The speed of travel, the wonders of information technology, the size of peoples hearts, the capacity to relieve suffering and instill hope had clearly tipped the scale in 30 years. What was remarkable yesterday is today manageable. We knew it from the podium – but more importantly – so did those in the audience.

Finally, there was a common awareness that health is being redefined and health care delivery reformed everywhere. The audience knew we do not have all the answers in the states – certainly not about prevention, or balance of life, or respect for our elders, or courage in the face of adversity, or spirituality, or peacefulness, or giving. We have a great deal to learn from them, as they do from us. This is not a perfect world. But it is better then we think. And what I learned in Norfolk at the Operation Smile meeting, is that we’re making progress.