TheAmsterdamDeclarationonEssentialSurgicalCareWorldJournalofSurgery(articleinpress)Matthijs Botman, Rinse J. Meester, Roeland Voorhoeve, Henning Mothes, Jaymie Ang Henry, Robert H. S. Lane, Michael H. Cotton, Hugo A. Heij, Edna Adan Ismail IntroductionOnbehalfofthesupportingorganisationsandallparticipantsoftheinternationalsymposium‘SurgeryinLowResourceSettings’,November2014,inAmsterdam,wepresentthe‘AmsterdamDeclarationonEssentialSurgicalCare’.ThesituationwithregardtoalackofsurgicalcapacityinLMICsisuntenableandurgentactionisrequiredtoalleviatethesituation.Manythousandsofpatientsaredyingunnecessarilyeverydaybecausethereisnoonetrainedtooperateonthem.Asaconsequence,thedeathtollofsurgicalconditionsinlowresourcesettingscurrentlyoutnumbersthedeathtollofHIV,malariaandTBcombined.Rarelyhastherebeensuchunanimityinthefieldofglobalsurgeryandthereisurgentactionneeded.ThelackofsurgicalcarewillbeontheagendaduringtheWorldHealthAssemblyinMay2015.WesolicitinternationalhealthpolicymakerstosupporttheinitiativetowardsaWHAresolutionon‘StrengtheningEmergencyandEssentialSurgicalCareandAnaesthesiaasacomponentofUniversalHealthCoverage.’Weneedtomaketheworldrealizethatwecompletelyforgotsomething:SurgeryshouldbepartoftheUnitedNations’post-2015sustainabledevelopmentgoalsasanessentialandnamedcomponentofuniversalhealthcoverage.

TheAmsterdamDeclarationonEssentialSurgicalCareBeingconcernedaboutthefactthat:

• Twobillionpeoplehavenoaccesstoessentialsurgicalcare1especiallyinlow-andmiddle-incomecountries

• Fivemillionpeoplediefrominjurieseveryyear;morethan90%ofwhomarefoundinlowresource

settings

• Athirdofamillionwomendieeveryyearfromchildbirth;15-20%ofwhomcanbesavedthroughsafeessentialsurgicalcare

• Twomillionwomenlivewithuntreatedobstetricfistula;allentirelyinlowresourcesettings

• Twentymillionpeoplesufferfromtreatableblindnesscausedbycataract

• Millionsofpeoplesufferfromcorrectablecongenitaldeformitiessuchascleftlipandclubfoot

• SurgicalconditionsnowkillmorepeoplethanHIV,TB,andMalariacombined

• Surgicalandobstetricconditionsapproximatelyaccountfor11%oftheworld’sdisability-adjustedlife

years(DALYs)losteachyear

• Thereisacriticalshortageinsurgicallyandanaestheticallytrainedhealthcareworkersinlow-andmiddle-incomecountries(forexample0.5surgeonper100.000peopleinSubSaharanAfrica)

• Themedicalinfrastructure,suppliesandobservedproceduresinlow-andmiddle-incomecountriesareinsufficienttoprovidetheneededessentialsurgicalcare

1Definition:Wedefineessentialsurgicalcareas:‘Basicsurgicalproceduresthatsavelivesandpreventpermanentdisabilityorlife-threateningcomplications.Suchsurgeryshouldbeofappropriatequalityandsafety,accessibleatalltimesandaffordabletothecommunity’

Proposedlistof15essentialsurgicalconditionsConditions Interventions

Obstructed labour Caesarean section. Symphysiotomy, assisted or manipulative delivery Severe uterine bleeding Evacuation of Retained Products of the Placenta, B-Lynch suture, repair of uterine perforation Surgical infections Incision and drainage of abscess, fasciotomy, dental extraction, tympanotomy, bone drilling, arthrotomy Severe wounds (including burns) Debridement, hemostasis, suturing, escharotomy, skin grafting Severe head injury Management of head injury, cranial burr holes, elevation of depressed skull fracture Airway obstruction Management of compromised airway, tracheostomy, cricothyroidotomy, removal of foreign body Chest injury and infections

Intercostal drainage, thoracostomy Acute Abdomen Emergency laparotomy including appendicectomy Fractures and Dislocations Reduction of fractures and dislocations, casting and splinting, external Fixation Severe limb ischemia, sepsis and injury Amputations Urinary outflow obstruction Suprapubic catheterization Hernia Hernia repair Cataract Cataract extraction and Intra-ocular lens insertion Clubfoot Casting and splinting, tenotomy Simple Cleft lip Cleft lip repair

Takingintoaccountthat:

• Atpresentthereislimitedglobaleffortfromapublichealthperspectivetoreducethenumberofdeathsanddisabilitiesinlow-andmiddleincomecountriescausedbysurgicalconditions

• EssentialsurgicalcareinlowresourcesettingsiscosteffectiveinDALYsandcostcompetitivetootherpreventivehealthmeasures

• Makingessentialsurgicalcareavailableinlowresourcesettingsrequiresamultilevelapproach

Wemakethefollowingdeclaration2:

• Wesolicitthesupportofthegovernmentsofallnations,theUN,theWHO,theWorldBank,institutionaldonorsaswellasothermajordonors,non-governmentalorganisations,allinvolvedmedicalandsurgicalsocieties,colleges,andprofessionalbodies.

Toensurethat:

Essentialsurgerybemadeavailabletoallregardlessofage,gender,race,ethnicgroup,geographicallocation,financialstatus,andpoliticalandreligiousaffiliationthroughthefollowingactions:

1. IncorporateessentialsurgicalcareaspartofnationalhealthserviceswithinUniversal

HealthCoverage(UHC)

2. Realignandincreasetheallocationofresourcestoimproveessentialsurgicalcaredelivery

3. Maketrainingaccessibletohealthworkersprovidingessentialsurgicalcare

4. Ensuretheprovisionofsupplies,equipment,andinfrastructureforsafe,essentialsurgicalcare

5. Developprotocolsforethicalsurgicalpractice,assessment,audit,andfollow-up

6. Optimizecollaborationamongstallstakeholderssuchasprofessionalorganizations,institutions,charities,andfundingagenciestoavoidduplicationandmaximizeeffortstopromoteessentialsurgicalcare

7. SupporttheproposedWorldHealthAssemblyresolution‘Strengtheningemergencyandessentialsurgicalcareandanaesthesiaasacomponentofuniversalhealthcoverage’inMay2015

2ThisDeclarationwasinitiatedduringthefinalsessionofthesymposium‘SurgeryinLowResourceSettings’onNovemberthe15th2014inAmsterdamwiththefollowingorganisationsrepresented:AMREFflyingdoctors,theAssociationofSurgeonsofGreatBritainandIreland,theCollegeofSurgeonsofEast,CentralandSouthernAfrica(COSECSA),CAPACARE,DoctorsWithoutBorders(MSF-Holland),EdnaAdanUniversityHospital,Emergency,theGermanSocietyforTropicalSurgery(DTC),theG4Alliance,theInternationalCollaborationforEssentialSurgery(ICES),theInternationalCommitteeoftheRedCross(ICRC),theInternationalFederationforRuralSurgery(IFRS),theInternationalFederationofSurgicalColleges(IFSC),MercyShips,theNetherlandsSocietyforInternationalSurgery(NVIC),theNetherlandsSocietyforPlasticSurgery(NVPC),VolonteersOverSeas(VSO),andtheWorldOrthopedicConcern(WOC)

Thisdeclarationissupportedby:

PraveenAggarwalAcademicCollegeofEmergencyExpertsinIndia

KellyMcQueenAllianceforSurgeryandAnesthesiaPresence

MichaelKleinAmericanPediatricSurgicalAssociation

JohnAbensteinAmericanSocietyofAnesthesiologists

MamtaSwaroopAssociationforAcademicSurgery

LindaGroahAssociationofperiOperativeRegisteredNurses

JohnMooreheadAssociationofSurgeonsofGBandIreland

RobertPierikAssociationofSurgeonsoftheNetherlands

RobertRivielloCenterforSurgeryandPublicHealth,BrighamandWomen'sHospital

PankajJaniCollegeofSurgeonsofEast,CentralandSouthernAfrica

KeithMartinConsortiumofUniversitiesforGlobalHealth

RobertNeighbourDiamedica

DeanJamisonDiseaseControlPriorities3thEdition

EdnaAdanIsmailEdnaAdanUniversityHospital

GinoStradaEmergency

VivekanandJhaGeorgeInstituteforGlobalHealth,India

HenningMothesGermanSocietyforTropicalSurgery

JohnMearaGlobalSurgeryandSocialChange,HarvardMedicalSchool

EricaFrenkelGradianHealthSystems

MichaelCottonInternationalCollaborationforEssentialSurgery

PeterReemstInternationalFederationforRuralSurgery

RobertLaneInternationalFederationofSurgicalColleges

JelleStekelenburgInternationalSafeMotherhoodandReproductiveHealth

HarshadSanghviJhpiegoCorporation

FizanAbdullahJohnsHopkinsGlobalSurgeryInitiative

MedgeOwenKybele,Inc.

PaulinePhilipLifeboxFoundation

WouterBakkerMedicalDoctorsinInternationalHealthandTropicalMedicineNetherlands(TROIE)

PeterLinzMercyShips

HenkKootNetherlandsOrthopedicAssociation

AnkievandenBroekNetherlandsSocietyforInternationalHealthandTropicalMedicine(NVTG)

RoelandVoorhoeveNetherlandsSocietyforInternationalSurgery

HenriWintersNetherlandsSocietyforPlasticSurgery

ElisabethOgboli-NwasorNigerianSocietyofAnaesthetists

RubenAyalaOperationSmile

SusanKoshyPan-AfricanAcademyofChristianSurgeons

SaraAndersonReSurgeInternational

DeclanMageeRoyalCollegeofSurgeonsinIreland

RosemaruMukunziRwandaSocietyofAnaesthesiologists

EmileRwamasiraboRwandaSurgicalSociety

RogerEltringhamSafeAnaesthesiaWorldwide

ShivaniGargPatelSamahope

ErinStieberSmileTrain

JohanDiedericksSouthAfricanSocietyofAnaesthesiologists

MiliardDerbewSurgicalSocietyofEthiopia

HugoHeijSymposiumSurgeryinLowResourceSettings

JaymieHenryTheRighttoHeal

JohnMcGrathUrolink,BritishAssociationofUrologicalSurgeons

JorisEekhoutVoluntaryServiceOverseas

DavidWilkinsonWorldFederationofSocietiesofAnaesthesiologists

AntoonSchlosserandMichaelLaurenceWorldOrthopedicConcern

AriannedeJongDoctorsoftheWorld,Netherlands