One click can save his life: Representing surgery

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Mark Shrime
Mark is a head and neck cancer and reconstructive surgeon in Boston, currently getting PhD in health policy from Harvard. He also works regularly in West Africa and writes on topics in global surgery.

Let’s be clear: Cleft lips (probably)* don’t kill people.

I say “probably” because the truth is, there’s no research on this. Yes, children born with cleft lip and palate have higher perinatal mortality rates. Yes, children with syndromes that include cleft lips have definitely shortened life spans. But cleft lip alone?  Nothing.

As far as we know, then, cleft lips don’t kill people. Why is this important?  Because advertisements such as the one on the right have been appearing on billboards, in newspapers, and online for at least the last year. A click of a mouse can save his life. It’s an attractive gimmick.

And it’s wrong.

But more on that in a little bit. I bring up this ad for a very particular reason:  Last month I wrote about the Rule of Rescue and its potential role in driving global health funding. In that post, I suggested that we needed to learn to represent non-communicable disease in a more robust, emotionally powerful way.

Of all non-communicable disease, however, surgical illnesses stand apart. We don’t  need to work to represent their emotional valence. Surgical disease epitomizes the Rule of Rescue. How intensely visceral is the picture of a girl with a cleft lip? a boy with club feet? a man with a tumor fungating off the side of his neck? These are penetrating images. They move us.

Why is it, then, that when surgical illness makes up a full 11% of disease worldwide, when cancer and road traffic accidents are within the top five causes of death in the developing world, when obstructed labor effects embarrassingly high rates of maternal mortality (and even more embarrassing rates of vesicovaginal fistulas)—why is it that low-income countries perform only 3.5% of all global surgeries? Why is it that the richest countries perform 11 surgeries per 100 people per year, and the poorest only 0.3?

It’s not because pictures don’t move us. Surgery, unlike other non-communicable diseases, is not a question of emotional potency.

We simply might not care. After all, we have other diseases to fix.

But what would we do if we did? Sheer numbers alone will not solve the problem. After all, we could increase the number of surgeries being performed in the developing world by increasing the number of surgeons that fly in, fix lips and palates, and fly out. This would definitely vitiate the 40-fold disparity (though, given the prevalence of cleft lips, not by much).

But we can—should—do better than that. Clefts are on the WHO’s list of essential surgical services. But so are traumas. And obstructed labor. And cancer.

And these don’t wait for the surgeon to fly in. These kill. And their treatment requires operating rooms—unfortunately, only 1 exists per 100,000 people in sub-Saharan Africa, compared to 25 here in the States—surgeons, anaesthesiologists, supplies, electricity, water, oxygen, medications, infrastructure. More importantly, these require innovation and problem solving in the face of resource constraint.

In short, these call for the full force of our public health, medical, surgical, human resource, structural, and financial knowledge.

Is the child in the ad worth all that? Absolutely.

The problem is, a click of the mouse won’t save his life. And until we start addressing surgical disease in a real, sustainable way, no amount of clicking will.

*If you know of any specific research in this area, please let me know.