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By Root 812 0

’s 193 member countries. And compiling the available numbers in surgery, my research team and I found that the WHO officials’ impression was correct: the global volume of surgery had exploded. By 2004, surgeons were performing some 230 million major operations annually—one for every twenty-five human beings on the planet—and the numbers have likely continued to increase since then. The volume of surgery had grown so swiftly that, without anyone’s quite realizing, it has come to exceed global totals for childbirth—only with a death rate ten to one hundred times higher. Although most of the time a given procedure goes just fine, often it doesn’t: estimates of complication rates for hospital surgery range from 3 to 17 percent. While incisions have gotten smaller and recoveries have gotten quicker, the risks remain serious. Worldwide, at least seven million people a year are left disabled and at least one million dead—a level of harm that approaches that of malaria, tuberculosis, and other traditional public health concerns.

Peering at the numbers, I understood why WHO—an organization devoted to solving large-scale public health problems—should suddenly have taken an interest in something as seemingly specific and high-tech as surgical care. Improvement in global economic conditions in recent decades had produced greater longevity and therefore a greater need for essential surgical services—for people with cancers, broken bones and other traumatic injuries, complications during child delivery, major birth defects, disabling kidney stones and gallstones and hernias. Although there remained some two billion people, especially in rural areas, without access to a surgeon, health systems in all countries were now massively increasing the number of surgical procedures performed. As a result, the safety and quality of that care had become a major issue everywhere.

But what could be done about it? Remedying surgery as a public health matter is not like remedying, say, polio. I’d traveled with WHO physicians overseeing the campaign to eradicate polio globally and seen how hard just providing vaccines to a population could be. Surgery was drastically more complex. Finding ways to reduce its harm in a single hospital seemed difficult enough. Finding a way that could reach every operating room in the world seemed absurd. With more than twenty-five hundred different surgical procedures, ranging from brain biopsies to toe amputations, pacemaker insertions to spleen extractions, appendectomies to kidney transplants, you don’t even know where to start. Perhaps, I thought, I could work with WHO to focus on reducing the harm of just one procedure—much like with central lines—but how much of a dent would that make in a problem of this scale?

In January 2007, at WHO headquarters in Geneva, we convened a two-day meeting of surgeons, anesthesiologists, nurses, safety experts, even patients from around the world to puzzle through what could be done. We had clinicians from top facilities in Europe, Canada, and the United States. We had the chief surgeon for the International Committee of the Red Cross, who had sent teams to treat sick and wounded refugees everywhere from Mogadishu to Indonesia. We had a father from Zambia whose daughter inadvertently suffocated from lack of oxygen during treatment. As the group told stories of their findings and experiences with surgery around the world, I became only more skeptical. How could we possibly attempt to address so many different issues in so many different places?

A medical officer in his forties from western Ghana, where cocoa growing and gold mining had brought a measure of prosperity, told of the conditions in his district hospital. No surgeon was willing to stay, he said. Ghana was suffering from a brain drain, losing many of its highest skilled citizens to better opportunities abroad. He told us his entire hospital had just three medical officers—general physicians with no surgical training. Nevertheless, when a patient arrives critically ill and bleeding after two days in labor, or sick and feverish