Statement of Purpose

• In low-income countries, more children over the age of five die from injuries than from malaria, tuberculosis, and AIDS combined
• Surgery has not been perceived as part of public health, especially in low-income countries
• Fifteen percent of the global burden of disease can be addressed with surgery
• In the next 20 years, road traffic injuries will rise to the top five causes of death and DALYs lost worldwide, ahead of all infectious diseases

There are major disparities in surgical and perioperative care worldwide. In many low-income countries, patients with surgical problems that would be routinely treatable elsewhere in the world, often present with advanced stages of disease or, more frequently, never even reach a care facility. Those patients who do reach a health care center often do not receive adequate treatment due to critical shortages of equipment and trained personnel.

Global Partners in Anesthesia and Surgery (GPAS) is a collabration formed by trainees and faculty at the University of California, San Francisco (UCSF) and partner institutions worldwide to address these challenges. GPAS aims to increase the resources available for patient care, medical training, and research in low-income countries through sustainable partnerships with academic centers and other organizations. Through these partnerships we hope to create model strategies for building local capacity, improving access to quality care, and ultimately reducing the global burden of surgical disease.

While infectious diseases such as HIV exact a great health toll in low-income countries, surgical conditions including trauma from road traffic crashes or other injuries, malignancies, soft tissue infections, congenital anomalies, and complications of childbirth also contribute significantly to the burden of disease and impede economic development. Surgical conditions account for approximately 11% of the global burden of disease, and for children in Africa between 5 and 18 years of age the World Health Organization (WHO) has reported that the burden of disease from injuries is greater than that for malaria, HIV, and tuberculosis combined. According to the WHO Global Burden of Disease Estimates in 2004, road traffic accidents are expected to increase from 9th to 3rd leading cause of disease burden worldwide, ahead of all infectious diseases.

To date, surgical services have been relatively neglected by international donors and the public health community for many reasons including greater donor focus on infectious diseases and a perceived lack of cost-effectiveness of treating surgical conditions in resource poor environments. Recent cost-effectiveness analyses suggest that provision of essential surgical services can be more cost-effective than HIV treatment, and even as cost-effective as some vaccination programs.

Additional factors contributing the global surgical and perioperative workforce crises are the significant cost and length of training. For example, in Uganda the annual cost of surgical or anesthesia training is approximately US $1000, more than twice the average annual per capita income. As a result, surgical and anesthesia programs are unable to fill training positions, and the already critically low number of surgeons and anesthesiologists is overwhelmed and at-risk for further decline. In Uganda, there are 4 physicians per 100,000 people (more than 60 times less than in the US), with only 100 surgeons and 10 Ugandan physician anesthesiologists for the entire population of 28.8 million. By contrast, in the United Kingdom there are approximately 20 anesthetists per 100,000 people, or 1000 more physician anesthetists than Uganda.

Although little is known about how best to organize training and delivery systems for surgical and perioperative care in resource-constrained areas, recent data demonstrate that this care can be provided in a cost-effective manner. GPAS utilizes a multidisciplinary approach to design, implement, and evaluate strategies to address the above challenges facing surgical and perioperative care in the developing world. In the short-run we hope to utilize academic and philanthropic support to increase resources available for patient care, teaching, research, and training thereby immediately enhancing local surgical capacity and improving access to quality care. By constantly evaluating our projects for sustainability, scalability, and cost-effectiveness, we hope to contribute to a reduction in the global burden of surgical disease in the long-term.

GPAS is currently focusing on projects in three key areas:

Workforce Expansion and Training

Currently in Uganda there are approximately 75 specialist surgeons and 10 physician anesthesiologists for a population of 30 million people. The training positions in the post-graduate programs are unfilled yearly due to difficulty recruiting and funding trainees. We hope to double this number by sponsoring Ugandan physicians wishing to pursue post-graduate studies in anesthesia and surgery. We also are actively lobbying the local health ministry to increase funding for these trainees. The annual cost of training for one surgeon or anesthesiologist in this program is approximately $2,500 U.S.

Sustainable Approaches to Infrastructure Improvement

In Uganda as in many low-income countries, no prehospital trauma system exists. Many patients arrive at the hospital too late for care, or often do not arrive at all. Evidence from other countries in the region suggests that only one-third of injured patients reach a health facility. Using training programs endorsed by the World Health Organization and adapted to a resource-constrained environment, GPAS has begun to conduct training courses for lay first responders such as police officers, public service vehicle drivers, and members of local government to improve the care of injured citizens. Through follow-up evaluation of this program we hope to achieve a measurable positive impact in Uganda and a program that can be implemented in other low-income countries.

Clinical Research and Collaboration

At the present time the dearth of surgical and perioperative research in low-income countries is a significant factor contributing to the inadequate provision of these services. GPAS currently has several on-going research collaborations in Uganda which aim to expand this body of knowledge. Our projects focus on the identifying the main causes of surgical and perioperative morbidity and mortality in a low-income environment, and then designing, introducing, and evaluating specific, practical, and potentially life-saving interventions to address these areas. GPAS faculty from UCSF and Makerere University actively mentor residents from both universities to help with research grant applications. As a result of this mentoring program, one competitive research grant has already been awarded to a trainee a Mulago and several more have been submitted.

To find out more information on the progress of our projects, please go to the GPAS Blog or visit our Projects Page.