Challenging the barriers to accessing surgery in low-resource settings: Lessons learned from burns

Surgery is a neglected component of primary health care in many parts of the world, with more than 2 billion people lacking access to essential surgical services.¹ Yet few international initiatives are working to promote surgery as a public health good or to fund capacity building, and even fewer are developing simple, cost-effective models to extend surgical coverage outside capital cities and beyond a limited range of indications. Factors contributing to this neglect range from pragmatic challenges, such as a lack of basic materials and infrastructure and insufficient numbers of trained surgeons,² to misconceptions³ which feed the false notion that these challenges are, practically speaking, insurmountable. Médecins Sans Frontières (MSF) is an international humanitarian organization that provides medical care in crisis situations, including conflict, natural disasters, epidemics, and failed health systems. Surgical services are deployed typically during the initial response to an emergency, such as an earthquake or violent conflict. If they are maintained after the immediate crisis has eased-a step sometimes taken in contexts with an acute lack of local capacity-then road traffic and domestic accidents, particularly burns, often come to dominate case etiologies. Surgical management of burns remains among the most neglected areas of surgery, and here, too, myths and misperceptions impede efforts to develop sustained capacity for managing this devastating, common injury. The experience of MSF offering surgical care in low-resource settings (LRS) has shown that burn management and other surgical services seen as "specialized" (and therefore as more difficult to provide) depend on the same fundamental hospital activities and capacities as do general and orthopedic surgery. In this article, we draw upon the work of MSF in burn care⁴ to illustrate these parallels and to examine the hurdles encountered and skills required in setting up surgical services in LRS. We also examine some of the misperceptions that impede development of critically needed capacity and describe how we are working to build a burn care model that is efficacious and transferrable in settings where we operate. Our approach draws on lessons learned from developing other types of surgical programs and should help inform efforts to expand both the geographical reach and the range of surgical services in LRS.