Public Health Awareness

Data from WHO and the World Bank indicate that scaling up infrastructure to enable access to surgical care in regions where it is currently limited or is non-existent is a low-cost measure relative to the significant morbidity and mortality caused by lack of surgical treatment.[112] In fact, a systematic review found that the cost-effectiveness ratio — dollars spent per DALYs averted — for surgical interventions is on par or exceeds those of major public health interventions such as oral rehydration therapy, breastfeeding promotion, and even HIV/AIDS antiretroviral therapy.[118] This finding challenged the common misconception that surgical care is financially prohibitive endeavor not worth pursuing in LMICs.

In terms of the financial impact on the patients, the lack of adequate surgical and anesthesia care has resulted in 33 million individuals every year facing catastrophic health expenditure — the out-of-pocket healthcare cost exceeding 40% of a given household's income.[110][119]

In alignment with the LCoGS call for action, the World Health Assembly adopted the resolution WHA68.15 in 2015 that stated, "Strengthening emergency and essential surgical care and anesthesia as a component of universal health coverage."[120] This not only mandated the WHO to prioritize strengthening the surgical and anesthesia care globally, but also led to governments of the member states recognizing the urgent need for increasing capacity in surgery and anesthesia. Additionally, the third edition of Disease Control Priorities (DCP3), published in 2015 by the World Bank, declared surgery as essential and featured an entire volume dedicated to building surgical capacity.[121]

A key policy framework that arose from this renewed global commitment towards surgical care worldwide is the National Surgical Obstetric and Anesthesia Plan (NSOAP).[122] NSOAP focuses on policy-to-action capacity building for surgical care with tangible steps as follows: (1) analysis of baseline indicators, (2) partnership with local champions, (3) broad stakeholder engagement, (4) consensus building and synthesis of ideas, (5) language refinement, (6) costing, (7) dissemination, and (8) implementation. This approach has been widely adopted and has served as guiding principles between international collaborators and local institutions and governments. Successful implementations have allowed for sustainability in terms of longterm monitoring, quality improvement, and continued political and financial support.[122]

The NIHR Global Health Research Unit on Global Surgery

Seven surgical research Hubs in Benin, Ghana, India, Mexico, Nigeria, Rwanda and South Africa with an extensive network of urban and rural ‘Spoke' hospitals have joined to create the NIHR.[123] The NIHR Global Health Research Unit on Global Surgery is led by the University of Birmingham[124] which provides overall oversight in relation to the Unit strategy, infrastructure and delivery, research and finance.

The network prioritized surgical topics that needed research and has performed multiple surgical studies. The network resulted in many research groups including GlobalSurg I, II, III[125] and COVIDSurg[126] and many other trials with worldwide collaborations as project FALCON,[127] CHEETAH,[128] GECKO, HIPPO,[129] MAGPIES, WOLVERINE and more.[130]

The research was published in over 40 articles in high impact journals in topics like surgical site infections,[131] COVID-19[132] and mortality.[133]

Other global surgery collaborations

More trials have emerged to assess surgical outcomes around the World using big data from thousands of centers. Other notable trials include:

Global PaedSurg; The study was published in The Lancet examined the risk of mortality for nearly 4000 babies born with birth defects in 264 hospitals around the world. The study found babies born with birth defects involving the intestinal tract have a two in five chance of dying in a low-income country compared to one in five in a middle-income country and one in twenty in a high-income country.[134][135]

APORG: The African Perioperative Research Group (APORG) was launched in South Africa

ASOS and ASOS-2: The studies showed that death after surgery is a major public health problem in Africa. Surgical patients in Africa are twice as likely to die in hospital following surgery when compared to the global average.[136][137]

ASOS PaedSurg: African Pediatric postoperative outcomes are poor, with up to 4x morbidity and 11x mortality rates than high income countries.[138]

ACCCOS: COVID-19 Mortality was higher in Africa than reported from studies done in other parts of the World.[139]

ACIOS (African Critical Illness Outcomes Study): 1/8 patients in African hospitals are critically ill with 20% 7 day mortality rate.[140]

Global Health Research Group on Children's Non-Communicable Diseases Collaborative

Many scholars from around the world have participated in overlapping trials whether as Principal Investigators, Dissemination Committee or Regional leaders to promote the research and oversee data collection. Notable collaborators from these networks include The list included key figures from around the World as Prof Bruce Biccard (South Africa), Prof Adesoji Ademuyiwa (Nigeria), Prof Kokila Lakhoo (Oxford, UK), Dr Naomi Wright (Oxford, UK), Dr Emrah Aydin (Turkey), Prof Mahmoud Elfiky (Egypt) and Prof Milind Chitnis (South Africa).[141]

Multimorbidity, age-related diseases and aging

Multimorbidity is "a growing public health problem worldwide", "likely driven by the ageing population but also by factors such as high body-mass index, urbanisation, and the growing burden of NCDs (such as type 2 diabetes) and tuberculosis in low- and middle-income countries (LMICs)".[142][143][144] Around the world, many people do not die from one isolated condition but from a multitude of factors and conditions.[additional citation(s) needed] A study suggested there is a paucity of multimorbidity and comorbidity data globally and mapped comorbidity patterns.[145]

With aging populations, there is a rise of age-related diseases which puts major burdens on healthcare systems as well as contemporary economies or contemporary economics and their appendant societal systems. Healthspan extension and anti-aging research seek to extend the span of health in the old as well as slow aging or its negative impacts such as physical and mental decline. Modern anti-senescent and regenerative technology with augmented decision making could help "responsibly bridge the healthspan-lifespan gap for a future of equitable global wellbeing".[146] Aging is "the most prevalent risk factor for chronic disease, frailty and disability, and it is estimated that there will be over 2 billion persons age > 60 by the year 2050", making it a large global health challenge that demands substantial (and well-orchestrated or efficient) efforts, including interventions that alter and target the inborn aging process.[147]

Infertility crisis

Further information: Male infertility crisis

A scientific review found that human sperm counts fell by 62% in the last 50 years, are decreasing at an accelerating rate and are decreasing worldwide,[148][149] likely a result of factors such as poor diets, endocrine disruptors in prevalent products, unhealthy lifestyles and toxic forever chemicals in air and water.[148]

Health interventions

See also: Health human resources

Global interventions for improved child health and survival include the promotion of breastfeeding, zinc supplementation, vitamin A fortification, salt iodization, hygiene interventions such as hand-washing, vaccinations, and treatments of severe acute malnutrition.[69][150][151] The Global Health Council suggests a list of 32 treatments and health interventions that could potentially save several million lives each year.[152]

Many populations face an "outcome gap", which refers to the gap between members of a population who have access to medical treatment versus those who do not. Countries facing outcome gaps lack sustainable infrastructure.[153] In Guatemala, a subset of the public sector, the Programa de Accessibilidad a los Medicamentos ("Program for Access to Medicines"), had the lowest average availability (25%) compared to the private sector (35%). In the private sector, the highest- and lowest-priced medicines were 22.7 and 10.7 times more expensive than international reference prices respectively. Treatments were generally unaffordable, costing as much as 15 days wages for a course of the antibiotic ceftriaxone.[154] The public sector in Pakistan, while having access to medicines at a lower price than international reference prices, has a chronic shortage of and lack of access to basic medicines.[155]

Journalist Laurie Garrett argues that the field of global health is not plagued by a lack of funds, but that more funds do not always translate into positive outcomes. The problem lies in the way these funds are allocated, as they are often disproportionately allocated to alleviating a single disease.[156]

Labor shortages

In its 2006 World Health Report, the WHO estimated a shortage of almost 4.3 million doctors, midwives, nurses, and support workers worldwide, especially in sub-Saharan Africa.[157] A 2022 study estimated that, "in 2019, the world had 104.0 million (95% uncertainty interval 83.5–128.0) health workers, including 12.8 million (9.7–16.6) physicians, 29.8 million (23.3–37.7) nurses and midwives, 4.6 million (3.6–6.0) dentistry personnel, and 5.2 million (4.0–6.7) pharmaceutical personnel" and found that sub-Saharan Africa, south Asia, and north Africa and the Middle East had the lowest densities of human resources for health.[158] However, even when only considering current technologies and processes (such as only little use of telehealth as of 2022), overall numbers of personnel and shortages do not consider sub-national geographic distribution of various types of health workers (or expertise).

Global health security

The COVID-19 pandemic has highlighted how global health security is reliant on all countries around the world, including low- and middle-income countries, having strong health systems and at least a minimum of health research capacities. In an article 2020 in Annals of Global Health,[159] the ESSENCE group outlined a mechanism for review of investment in health research capacity building in low- and middle-income countries. The review mechanism will give funders of research for health the information to identify the gaps in the capacity that exist in low- and middle-income countries and the opportunity to work together to address those disparities. The overall goal is increased, coordinated support of research on national health priorities as well as improved pandemic preparedness in LMICs, and, eventually, fewer countries with very limited health research capacity.

Global factors impacting health

Climate change

This section is an excerpt from Effects of climate change on human health.[edit]

Example of impacts on health: Heat stroke treatment at Baton Rouge during the 2016 Louisiana floods. Climate change is making heat waves more intense, potentially leading to a higher risk of heat stroke.

The effects of climate change on human health are profound because they increase heat-related illnesses and deaths, respiratory diseases, and the spread of infectious diseases. There is widespread agreement among researchers, health professionals and organizations that climate change is the biggest global health threat of the 21st century.[160][161]

Rising temperatures and changes in weather patterns are increasing the severity of heat waves, extreme weather and other causes of illness, injury or death. Heat waves and extreme weather events have a big impact on health both directly and indirectly. When people are exposed to higher temperatures for longer time periods they might experience heat illness and heat-related death.[162]

In addition to direct impacts, climate change and extreme weather events cause changes in the biosphere.[163][164] Certain diseases that are carried and spread by living hosts such as mosquitoes and ticks (known as vectors) may become more common in some regions. Affected diseases include dengue fever and malaria.[162] Contracting waterborne diseases such as diarrhoeal disease will also be more likely.[165]

Changes in climate can cause decreasing yields for some crops and regions, resulting in higher food prices, less available food, and undernutrition. Climate change can also reduce access to clean and safe water supply. Extreme weather and its health impact can also threaten the livelihoods and economic stability of people. These factors together can lead to increasing poverty, human migration, violent conflict, and mental health issues.[166][167]

Climate change affects human health at all ages, from infancy through adolescence, adulthood and old age.[162] Factors such as age, gender and socioeconomic status influence to what extent these effects become wide-spread risks to human health.[168]: 1867  Some groups are more vulnerable than others to the health effects of climate change. These include children, the elderly, outdoor workers and disadvantaged people.[162]: 15 

A comprehensive annually scheduled study finds climate change is "undermining every dimension of global health monitored" and reports dire conclusions from tracking of impact indicators.[169][170] The effects of climate change have also increased the risk of health conditions, such as lung disease or asthma which are caused by air pollution.[171] These medical conditions are caused due to extreme heatwaves or by "higher concentrations of ground-level ozone".[171]

Antimicrobial resistance

This section is an excerpt from Antimicrobial resistance.[edit]

Two petri dishes with antibiotic resistance tests

Antibiotic resistance tests: Bacteria are streaked on dishes with white disks, each impregnated with a different antibiotic. Clear rings, such as those on the left, show that bacteria have not grown—indicating that these bacteria are not resistant. The bacteria on the right are fully resistant to three of seven and partially resistant to two of seven antibiotics tested.[172]

Antimicrobial resistance (AMR or AR) occurs when microbes evolve mechanisms that protect them from antimicrobials, which are drugs used to treat infections.[173] This resistance affects all classes of microbes, including bacteria (antibiotic resistance), viruses (antiviral resistance), parasites (antiparasitic resistance), and fungi (antifungal resistance). Together, these adaptations fall under the AMR umbrella, posing significant challenges to healthcare worldwide.[174] Misuse and improper management of antimicrobials are primary drivers of this resistance, though it can also occur naturally through genetic mutations and the spread of resistant genes.[175]

Antibiotic resistance, a significant AMR subset, enables bacteria to survive antibiotic treatment, complicating infection management and treatment options.[174] Resistance arises through spontaneous mutation, horizontal gene transfer, and increased selective pressure from antibiotic overuse, both in medicine and agriculture, which accelerates resistance development.[176]

The burden of AMR is immense, with nearly 5 million annual deaths associated with resistant infections.[177] Infections from AMR microbes are more challenging to treat and often require costly alternative therapies that may have more severe side effects.[178] Preventive measures, such as using narrow-spectrum antibiotics and improving hygiene practices, aim to reduce the spread of resistance.[179] Microbes resistant to multiple drugs are termed multidrug-resistant (MDR) and are sometimes called superbugs.[180]

The World Health Organization (WHO) claims that AMR is one of the top global public health and development threats, estimating that bacterial AMR was directly responsible for 1.27 million global deaths in 2019 and contributed to 4.95 million deaths.[181] Moreover, the WHO and other international bodies warn that AMR could lead to up to 10 million deaths annually by 2050 unless actions are taken.[182] Global initiatives, such as calls for international AMR treaties, emphasize coordinated efforts to limit misuse, fund research, and provide access to necessary antimicrobials in developing nations. However, the COVID-19 pandemic redirected resources and scientific attention away from AMR, intensifying the challenge.[183]

AMR has been described as a leading global health issue. Globally, 1.27 million deaths in 2019 were attributable to AMR. That year, AMR may have contributed to 5 million deaths and one in five people who died due to AMR were children under five years old.[184]

Organization

Governmental or inter-governmental organizations focused on global health include:

The United Nations

World Health Organization

International Agency for Research on Cancer (IARC)

WHO Centre for Health Development (WKC)

United Nations Children's Fund (UNICEF)

World Food Programme (WFP)

Pan American Health Organization (PAHO)

International Committee of the Red Cross

Centers for Disease Control and Prevention (CDC)

The Global Fund to Fight AIDS, Tuberculosis and Malaria

President's Emergency Plan for AIDS Relief (PEPFAR)

Non-governmental organizations focused on global health include:

Médecins Sans Frontières (Doctors Without Borders, MSF)

Bill & Melinda Gates Foundation

Governments and analysis

A study of select global health related organizations and initiatives suggests that major trends in global health governance appear to be "towards more discretionary funding and away from core or longer-term funding; towards defined multi-stakeholder governance and away from traditional government-centred representation and decision-making; and towards narrower mandates or problem-focused vertical initiatives and away from broader systemic goals".[185] There is a growing willingness to use militaries in state-led support of global health efforts which have capabilities ranging from "research, surveillance, and medical expertise to rapidly deployable, large-scale assets for logistics, transportation, and security".[186]

Global Health Security Agenda

The Global Health Security Agenda (GHSA) is "a multilateral, multi-sector effort that includes 60 participating countries and numerous private and public international organizations focused on building up worldwide health security capabilities toward meeting such threats" as the spread of infectious disease. On March 26–28, 2018, the GHSA held a high-level meeting in Tbilisi, Georgia, on biosurveillance of infectious disease threats, "which include such modern-day examples as HIV/AIDS, severe acute respiratory syndrome (SARS), H1N1 influenza, multi-drug resistant tuberculosis—any emerging or reemerging disease that threatens human health and global economic stability".[187] This event brought together GHSA partner countries, contributing countries of Real-Time Surveillance Action Package, and international partner organizations supporting the strengthening of capacities to detect infectious disease threats within the Real-Time Surveillance Action Package and other cross-cutting packages.[188]

GHSA works through four main mechanisms of member action, action packages, task forces and international cooperation. In 2015, the Steering Group of the GHSA agreed upon the implementation of their commitments through 11 Action Packages. Action Packages are a commitment by member countries and their partners to work collaboratively towards development and implementation of International Health Regulations (IHR).[189] Action packages are based on GHSA's aim to strengthen national and international capacity to prevent, detect, and respond to infectious disease threats. Each action package consists of five-year targets, measures of progress, desired impacts, country commitments, and list of baseline assessments.[190] The Joint External Evaluation process, derived as part of the IHR Monitoring and Evaluation Framework is an assessment of a country's capacity for responding to public health threats.[189] So far, G7 partners and EU have made a collective commitment to assist 76 countries whereas the US committed to helping 32 countries to achieve GHSA targets for IHR implementation. In September 2014, a pilot tool was developed to measure progress of the Action Packages and applied in countries (Georgia, Peru, Uganda, Portugal, the United Kingdom, and Ukraine) that volunteered to participate in an external assessment.[191]