Voices beyond the Operating Room: centring global surgery advocacy at the grassroots.

The neglected stepchild of global health?

Farmer and Kim, cofounders of Partners In Health, famously declared surgery the neglected stepchild of global health.1 They highlighted the high mortality and morbidity of conditions amenable to surgical interventions, especially in low-income and middle-income countries (LMICs), and the inequities in access to quality surgical care even within countries. Their call for global health leaders and practitioners to draw attention to the plight of the surgical patient in under-resourced areas catalysed the global surgery movement.

Is surgery still the neglected stepchild of global health? Fourteen years later, in a recent interview, Farmer stated that surgery, obstetrics and anaesthesia have lost this title and are now the most exciting parts of global health equity.2 This bold declaration indicated that the global community had finally started paying attention to the importance of surgery, anaesthesia and obstetrics. While some progress has been made towards equity in global surgery over the past decade, especially by advocacy at the international level, global surgery advocates have not yet achieved the goal of the movement—to ensure access to quality life-saving surgical and anaesthesia care for under-resourced communities.

In this article, we briefly discuss the progress towards global surgery equity since Farmer and Kim’s publication.1 We examine the successes of the HIV/AIDS global health movement and its use of grassroots advocacy. We argue that global surgery advocacy needs to be community-centred—as this is where the consequences of poor-quality surgical services are lived daily by providers and patients alike.

Progress in global surgery advocacy

Before Farmer and Kim’s 2008 article,1 the only known effort at WHO to support the needs of surgical patients was in 1980 by the then WHO director general Mahler. In his speech to the World Congress of the International College of Surgeons, Mahler noted that the vast majority of the world’s population had no access to any surgical care and little was being done to address this.3 Since then, global surgery has become a bona fide global health movement. Global surgery as access to equitable surgical and anaesthesia care was defined by the landmark publications of the Lancet Commission on Global surgery, and the Diseases Control Priorities 3 in 2015.4 5 Furthermore, in 2015, the World Health Assembly (WHA) passed Resolution 68.15, and WHA decision 70(22) in 2017, recognising surgical and anaesthesia care as essential for universal health coverage and requiring the director-general to report on the progress of its implementation, respectively.6 7 The efforts of various coalitions have led to the recent inclusion of global surgery in the US 2020 Appropriations bills directing the United States Agency for International Development (USAID) to support global surgery financially.8 9

In addition, several countries have developed National Surgical, Obstetric, Anaesthesia Plans (NSOAPs), as comprehensive policy commitments to strengthen surgical systems at the domestic level.10–13 Given this progress, it is possible to conclude that surgery has moved beyond the operating room and is no longer a neglected stepchild of global health.

Nonetheless, global surgery advocacy has not translated into better access and outcomes for surgical patients. Although many countries have developed NSOAPs, governments have allocated very little resources for their implementation.14 While surgical conditions account for more annual deaths than HIV/AIDS, malaria and tuberculosis combined, resources allocated to non-communicable diseases continues to pale in comparison to funds for infectious diseases.15 16 Recently, global resources have been diverted to fighting the COVID-19, making improving surgical care a herculean task.17

We purport that grassroots advocacy, that amplifies the voices of front-line care providers and communities affected by surgical conditions, is required to move global surgery from advocacy to implementation and gain political priority at the domestic and international levels. Their voices must echo in the corridors of power so that surgery and anaesthesia become a priority at the spending level to implement resolutions and plans.

Grassroots advocacy in global health

The extent to which grassroots advocacy entities can urge international and national political authorities to address global health issues is one of the determining factors of political priority for global health issues.18 While policy-makers are important, individuals and communities directly affected by weak surgical systems, such as patients and local surgical providers, are often the most powerful change agents for policymakers and funders.19 Grassroots advocacy by civil society organisations has always been at the centre of successful and impactful global health policies.

The power of grassroots advocacy, often acknowledged retrospectively, was evident during the HIV/AIDS epidemic. Significant pressure from grassroots advocacy groups on domestic politicians and international agencies led to increased financial resources for the fight against HIV/AIDS, ultimately leading to establishing the US President’s Emergency Fund for AIDS Relief. Coalitions of patients and advocacy groups, such as AIDS Coalition to Unleash Power (ACT UP) in the USA and Treatment Action Campaign (TAC) in South Africa, among others, led grassroots level campaigns for the reduction of the cost of the antiretroviral drug azidothymidine and advocated for the prioritisation of treatment for HIV patients.20 These grassroots advocacy groups engaged in civil disobedience, peaceful street demonstrations, and distributed data-driven pamphlets. In South Africa, TAC-led street marches drew significant international media attention and put pressure on the government to introduce antiretroviral therapy for hundreds of thousands of South Africans.20 People who had been directly affected by HIV/AIDS advocated passionately for policy change. The success of the global HIV/AIDS movement can be significantly attributed to the numerous coalitions of grassroots advocates.

Who are surgical communities?

It is easy to misrepresent the surgical community as a conglomerate of the top names of the global surgery movement or national leaders in surgery. In reality, it is a complex ecosystem of surgical providers and patients. The provider community includes specialist and non-specialist surgical and anaesthesia providers, nurses, community health workers, biomechanical engineers, theatre cleaners, physiotherapists and other carders, without whom surgical care would not be possible. The patient community, which has been visibly absent in global surgery discourse, includes patients, caregivers, patient advocacy groups and community leaders. This reality implies that the most revered voices may not be the most relevant, representative or consequential.

Local surgical communities equally consist of professional associations, which can be institutional, subnational, national, regional or international. These associations often represent the collective voices of surgical providers and should be key players in grassroots advocacy efforts. Very often policies made in government and legislative offices do not seek the input of these voices and when developed, do not trickle down to these implementers in a coherent way.

Centring global surgery advocacy at the grassroots

To attain global surgery goals and generate effective political priority for implementation, a strategy combining high-level advocacy and grassroots community advocacy is needed. Effective grassroots advocacy will require the problem of poor access to surgical care to become a topic of discussion and debate on local television and radio stations. Local newspapers, social media and news outlets often report the rising burden of trauma from road traffic accidents or non-communicable diseases and cancers. These conditions may be used as entry points to generate discussion about the value of improved surgical care at all levels of healthcare. Unlike HIV/AIDS, surgical patients are defined by the interventions they require and not a single disease. This means building a coalition around surgical conditions may be a challenge. Global surgery advocates will need to find ways to educate and bring surgical communities together and organise themselves as a single voice to better advocate. Drawing on lessons from the HIV/AIDS movement, Basilico et al, suggest some strategies that could be used to advocate for surgical care at the grassroots (table 1).20

Table 1

Advocacy strategies for centring global surgery advocacy at the grassroots20

Advocacy strategy	Description
Engage in critical self-reflection	Begin with individual introspection to consider own position, sources of inspiration, and potential role in movement.
Finding right partners	Find groups and individuals who understand the local policy process and political environment. Groups that share interests and understand the power of partnerships. This must include people who understand and are affected by the problem.
Know the issues	Effective advocates need to be well informed about the key global surgery issues and local political climates, such as exploring issues that particular political leaders may leverage.
Start a dialogue with policy makers	Engage representatives of local and national government and try to understand positions and concerns with your cause. Try to align their interest with the global surgery equity movement. Can they be champions or introduce legislation on global surgery?
Highlight key issues	Find creative ways to demonstrate the importance of global surgery such as calling and writing officials, drafting petitions, social media campaigns and op-ed writings.
Organise a public demonstration	One of the most effective ways to raise the visibility of a particular issue is through public displays such as protests, boycotts, and performance arts. Press coverage of these events can amplify the message to the public and decision-makers.
Build a coalition	Consider setting up a broad base of advocates, including community leaders, religious leaders, professional societies, patient advocacy groups, students and informal networks.
Be the change	Thoughtfulness and being willing to listen to varying perspectives is vital when building a grassroots advocacy campaign. Listen carefully to others before speaking even when you may disagree. Empathy can be a powerful way to connect and create solidarity for the global surgery cause.

The recent rise in the number of global surgery education programmes based in LMICs is a welcome step in the direction towards grassroots. A critical mass of global surgery programmes in LMICs should be established to build local capacity and to coordinate efforts locally with different stakeholders. We encourage these groups to work together and form coalitions to educate and empower communities at the grassroots to advocate for quality surgical care for all. Global surgery advocates have urged policy-makers and funders to develop a mechanism for pooling resources, much like the Global Fund for AIDS, tuberculosis and malaria, to strengthen surgical systems in LMICs. However, a brief study of the history of the creation of the Global Fund reveals that grassroots political advocacy was the key ingredient that led to the creation of this fund.21 Such a ‘Global Fund for Surgery’, as many advocate for, will need a significant push from the grassroots level to be successful and considered a political priority. Conversely, the entity should include meaningful representation from civil and professional societies within its governance structure.

In conclusion, Farmer’s recent proclamation that surgery is no longer the neglected stepchild of global health underscores the progress made in global surgery over the decade. Nonetheless, the global surgery movement has more grounds to cover to ensure that surgery is well established as a public health issue. Grassroot advocacy can move global surgery from advocacy to implementation.