New research from the Johns Hopkins Bloomberg School of Public Health suggests that the world's estimated 60 million refugees, displaced from their homes due to conflict, persecution or human rights violations, may need at least 2.78 million surgeries a year, something thought to be very difficult to arrange in the midst of their upheaval.
The researchers say that the findings, published online May 25 in the World Journal of Surgery, shed light on something that few governments and humanitarian aid organizations plan for when preparing for a large influx of displaced persons who are far from home and often in countries where there are already great unmet needs for surgical procedures.
"We are facing the largest forced migration crisis since World War II," says study leader Adam Kushner, MD, MPH, an associate in the Department of International Health at the Bloomberg School. "And while surgery is a critical component of health care, it is often neglected in times of crisis. Without access to timely and safe surgery, many people will become disabled and many will die -- outcomes that could have been prevented. What many people also do not realize is that many types of surgical care are easy to do and very cost effective."
The types of necessary surgeries run the gamut, from the repair of hernias and broken limbs, to C-sections and cleft lips and gallbladder removals, even stitches and burn care - any type of procedure that would be needed in any other population. In times of war, surgeries related to trauma, violence and burns may be particularly needed. The researchers could not say exactly how many refugees receive surgical care annually.
For their study, Kushner and his colleagues collected data from the United Nations High Commissioner for Refugees (UNHCR) and the United Nations Relief and Works Agency for Palestine Refugees in the Near East on the number of refugees, internally displaced persons and asylum seekers around the world and on their demographics. To estimate the number of procedures needed per year, they used a previously published minimum of 4,669 annual procedures per 100,000 population, a number similar to the target minimum surgical rate of 5,000 per 100,000 published by the Lancet Commission on Global Surgery. Eighty-five percent of the world has surgical volumes that fail to meet the minimum target of 5,000 per 100,000 - particularly in the regions of Africa, the Middle East and Asia, which host 78 percent of all forcibly displaced persons globally.
At the end of 2014, 59.5 million people were living as forcibly displaced persons, a number that has steadily increased in recent years, according to the UNHCR. The agency estimated that 218,000 persons entered Europe by sea in October 2015 alone, many of whom were seeking refuge from the violence in Syria.
While up to five percent of the population at large will require surgery, the World Health Organization estimates that as many as 15 percent of pregnant women will experience obstetric complications requiring surgery for conditions such as protracted labor, pre-eclampsia or ectopic pregnancy. The prevalence of pregnancy among displaced women of reproductive age is between six and 14 percent, they say. Pediatric needs are also very high, Kushner says.
While many refugees live in camp settlements, more than half live in established communities, yet they are typically precluded from accessing essential surgery due to a lack of proper documentation, high costs or weak surgical infrastructure in their host country.
"When planning to take care of refugees, much thought is put into how to house and feed and clothe people who are far from home for circumstances often beyond their control," Kushner says. "But surgery is a basic need and nobody talks about this."
"Global Estimation of Surgical Procedures Needed for Forcibly Displaced Persons" was written by Yuanting Zha, BS; Barclay Stewart, MD, MPH; Eugenia Lee, MD; Kyle N. Remick, MD; David H. Rothstein, MD, MS; Reinou S. Groen, MD, MIH, PhD; Gilbert Burnham, MD, PhD; David K. Imagawa, MD, PhD and Adam L. Kushner, MD, MPH.
This study was funded in part by a grant from the Fogarty International Center at the National Institutes of Health (R25-TW009345).