Investing in surgical systems supports pandemic preparedness
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Making COVID-19 vaccines widely available is a worthy track for U.S. global health leadership. But we need to do more. The coronavirus pandemic has shined a bright spotlight on the underlying problems that hampered the fight against COVID-19, contributed to avoidable deaths, and will cost lives in the future if not addressed.

While 30 percent of the global disease burden is surgical, health systems in low- and middle-income countries (LMICs) often lack the space (operating theaters and hospital rooms), the staff (surgeons, anesthesiologists, and nurses), and the stuff (ventilators, beds, personal protective equipment and medical supplies) necessary to meet the medical and surgical needs of their population. When the pandemic surges hit, like what we just saw in India, thousands can die from not being able to receive medical care as critical resources like oxygen and ventilators ran out.

Furthermore, whatever little surgical care these fragile surgical systems in LMICs were providing prior to the pandemic came to a halt as the surges came. This resulted in the mounting backlogs of elective surgical cases. According to one estimate, during a 12-week period in 2020, over 28 million operations were cancelled or postponed worldwide. That backlog alone would take 45 weeks to clear. These cancelled cases, which hit the poorest countries the hardest, include operations for conditions such as cancer where delay in treatment often result in worse outcomes.


When hospitals in high-income countries faced surges of patients arriving in their emergency rooms, they had a relief valve. By repurposing existing surgical capacity, they immediately gained up to 30 percent of additional treatment capacity. Operating rooms and recovery rooms became ICUs, surgeons became intensivists and anesthesiologists and anesthetists staffed intubation teams for COVID-19 patients who needed to be placed on ventilators. Existing surgical capacity became a highly valuable asset during pandemic surges. However, in most countries, surgical systems are grossly insufficient, leaving 5 billion people without access to timely, safe, and affordable surgical care — and hospital systems without surge capacity.

But the global effort to strengthen surgical care and anesthesia in low- and middle-income countries is building momentum. Sparked by a World Health Assembly resolution that the U.S. co-sponsored in 2015, the 16 members of the Southern Africa Development Community, the 37 members of the WHO Western Pacific region, and many others are actively developing policies and seeking financing to support country-wide surgical system scale-up. The U.S. has an opportunity to accelerate the path to pandemic preparedness for the LMICs by supporting health system strengthening in addition to vaccines.

The Congress is currently considering the State and Foreign Operations budget bill for FY22. For this fiscal year (2021), The State and Foreign Operations report contains language that directs the US Agency for International Development to support “strengthening surgical health systems” in partner countries. Many countries are developing surgical capacity building projects to address the unmet surgical needs for injuries, cancers, congenital conditions, maternal and child health. These projects are aimed at achieving key health targets of the Sustainable Development Goals such as reducing maternal and child deaths, reducing death and disability from road traffic injuries, reducing deaths from Non-Communicable Diseases. But they also recognize that the increased surgical capacity contributes to the country’s pandemic strategy. In fact, we have argued that investing in surgical systems is a “best buy” when building resilient health systems because of its versatility.

But because no specific figure was appropriated for these activities, the proposals have little chance of funding under existing earmarks and legacy programs. By appropriating even a small amount of dedicated funding for strengthening surgical systems, the Congress can empower USAID to address the immediate surgical backlog caused by COVID-19, while making a strategic investment in short- and long-term capacity improvements to deal with the current, and future, pandemics.

Jimmy Kolker served as the U.S. ambassador to Burkina Faso and Uganda and as Assistant Secretary for Global Affairs in the Department of Health and Human Services. Kee B. Park is the Director of Policy and Advocacy for the Program in Global Surgery and Social Change and a lecturer in the Department of Global Health and Social Medicine at Harvard Medical School.