Developing a vision and strategy for global vascular surgery within the Vascular Society of Great Britain & Ireland

Introduction

Global surgery is a field encompassing research, education and advocacy, which aims to improve health outcomes and achieve equitable surgical and anaesthetic care for all.¹ Within the field of global surgery there is a special emphasis on underserved populations such as those in low- and middle-income countries (LMICs) and those facing a humanitarian crisis.² The 2015 Lancet Commission on Global Surgery brought the scale of surgical inequity into focus, demonstrating that the poorest third of the world receive only 3–6% of operations whilst the richest third receive 75%.² It estimated that 16.9 million deaths annually are from conditions requiring surgical care, more than HIV/AIDS, malaria and tuberculosis combined, and that 77 million disability-adjusted life years lost could be averted by providing basic surgical care.³

In the context of global surgery, vascular diseases represent a significant and growing burden. For instance, 81% of people with diabetes mellitus (DM) currently live in LMICs, and 77% of those with DM in LMICs have significant unmet needs including a lack of access to diagnostics and medical therapies, resulting in poor DM control and increased DM-related complications.⁴ Meanwhile, the prevalence of peripheral artery disease (PAD) increased by 102% between 1990 and 2021.⁵ Recent evidence predicts a further substantial increase in the global prevalence of vascular diseases in the coming decade. The number of people living with DM globally is projected to rise by 45% between 2024 and 2050, with 95% of this increase occurring in LMICs.⁵ Over the same period, the number of people with PAD worldwide is expected to rise by 220%, with more than 50% of PAD cases in 2050 expected to occur in LMICs.⁷

In addition, the global burden of traumatic and conflict-related injury is rising,⁸ with a growing proportion of vascular injuries seen.^9,10 Reporting of conflict-related trauma varies considerably, so the exact burden remains uncertain, with little evidence from large-scale conflicts such as in Sudan and Syria.^11-13 However, available data from Ukraine reports that extremity vascular injuries have accounted for 12–14% of combat-related wounds in the war so far, higher than in some previous conflicts.^14,15

Taken together, these trends indicate a rise in the prevalence of conditions which require vascular expertise. Despite this, there are few dedicated global vascular surgery initiatives, and vascular surgery remains an under-represented specialty in global surgery discourse. A bibliometric analysis published in 2019 showed that, of 1623 articles published on global surgery between 1987 and 2017, only 11 could be attributed to vascular surgery.¹⁶

To this end, and in line with the Vascular Society of Great Britain and Ireland (VSGBI)’s core objectives, we are establishing the VSGBI Global Health Subcommittee, with the overarching aim of supporting the development of local teams to deliver high-quality vascular surgery services for patients in need globally. To achieve this, the Global Health Subcommittee will build a community of practice amongst UK surgeons with an interest in global surgery, as well as developing strategic, equitable and collaborative partnerships with international surgical societies and developing educational and research initiatives which are responsive to locally-led needs. Through this work, the Subcommittee aims to strengthen opportunities for advocacy and raise the profile of vascular surgery in high level global health policy discussions.

 

Building a community of practice

Building a community of practice will reduce silos and maximise the impact of work related to the provision of vascular services in a global setting, facilitating sharing of resources and collaboration amongst members. It will establish and map the ongoing work of vascular clinicians engaged in global surgery, identifying opportunities for collaboration and cooperation, and it will aid in understanding the work in which individuals may be interested in becoming involved.

 

Education and training

Postgraduate education and training in vascular surgery is limited in LMICs, where it is often fragmented.¹⁷ General surgeons manage most vascular emergencies in these settings, including the complex vascular injuries seen in trauma and conflict, and often receive little or no structured exposure to vascular techniques.¹⁸ This has resulted in high demand for courses which aim to teach the basics of vascular surgery in LMICs, and trauma and humanitarian settings.¹⁹ This Subcommittee will endeavour to contribute to vascular surgery education and training. It will do so in a needs-led rather than supply-led way by engaging local partners to identify priorities, before working with VSGBI members and key stakeholders to deliver educational resources and training which are context-specific and relevant. This may include support for regional vascular skills courses, curriculum development for vascular content within surgical training, remote and blended learning, reciprocal fellowships and observership opportunities. Critically, the primary goal is not for surgeons from Great Britain and Ireland to operate abroad, but to support the development of a self-sustaining vascular surgical workforce educated and retained within its own health system.

 

Research

A significant obstacle to providing adequate vascular care in many LMICs and conflict and disaster settings is the lack of reliable data on the burden of vascular diseases and injuries and their outcomes. This is particularly the case when examining LMICs individually rather than as a homogenous group. For instance, what may be true of upper-middle income countries in Asia may not be true of low-income countries in East Africa. There is growing recognition of the need for surgical research as part of an agenda to increase data-driven practice. Collaborative and co-designed models, such as those undertaken by the National Institute for Health and Care Research Global Surgery Unit at the University of Birmingham, and King’s Global Health Partnerships, have demonstrated that high-quality prospective clinical trials and implementation studies are achievable in resource-limited settings. In addition, there is growing research collaboration between surgical societies and organisations involved in conflict zones. This Subcommittee will seek to extend vascular research in this context by supporting prospective epidemiological and registry-based studies in LMICs and conflict and disaster settings, in the first instance. In time it will aim to progress to implementation-based research. It will promote locally-led research agendas and aim to embed equitable authorship and data ownership from the outset. Research capacity building – ie, training in research methodology and mentorship of LMIC investigators – will be treated as an output and not a byproduct. This will aim to nurture research collaboratives and facilitate an evidence base to support local researchers and clinicians to advocate for vascular surgery, ensuring its inclusion as part of universal health coverage.

 

Advocacy

While establishing an evidence base is key, as the Lancet commission has demonstrated, evidence alone does not change policy.²⁰ Up to this point, vascular surgery has not been actively advocated for in the global surgery and non-communicable disease discourse, despite sitting at the intersection of the two. National Surgical, Obstetric and Anaesthesia plans rarely mention vascular services.²¹ Global diabetes strategies advocate prevention and glycaemic control but rarely mention the surgical care of established complications.²² This Subcommittee will advocate the inclusion of vascular care within national surgical planning, with limb salvage a possible measurable health system outcome. Amputation carries substantial lifelong costs to individuals, families and society, so the case is economic as well as clinical.²³

 

Building sustainable partnerships

VSGBI already collaborates with international vascular societies in  a variety of ways. This Subcommittee will extend this approach, engaging directly with partner organisations to understand the most pressing, feasible and appropriate avenues of collaboration. It will build partnerships with surgical societies in countries where vascular societies do not yet exist, working with interested parties such as the national surgical societies as well as societies in aligned fields – for example, World Orthopaedic Concern. This Subcommittee will take a holistic and health systems approach to improving the provision of vascular surgery. Training a vascular surgeon serves little purpose if the health system means that patients are not able to reach hospital in a timely fashion or risk impoverishment due to the out-of-pocket costs of surgery. Vascular surgery provision depends as much on the presence of a vascular surgeon as it does on financing mechanisms, supply chains for equipment and consumables, referral networks and service delivery infrastructure, including theatre and nursing teams. These determinants lie largely outside the remit of vascular surgery itself, which is precisely why partnerships with non-vascular organisations working on these issues will be as integral to the Subcommittee’s strategy as those with vascular surgical societies.

 

Why now?

The establishment of this Subcommittee comes at a time of increasing interest in global engagement from VSGBI members, many of whom are already working on humanitarian and global health-related projects and initiatives, without a single vascular forum to share ideas, collaborate or pool resources for greater impact. Other surgical specialty organisations in the UK have already shown what is possible. The British Association of Paediatric Surgeons has a well-established International Affairs Committee. This promotes and facilitates international exchange of professional and educational values in paediatric surgery, as well as neonatal skills courses.²⁴ The British Association of Urological Surgeons (BAUS) has established Urolink, which represents BAUS in LMICs and contributes to health improvement projects, training, education and the provision of equipment and advice.²⁵

The establishment of this Subcommittee also comes at a crossroads internationally. Armed conflict rates are rising, resulting in both an increase in the humanitarian cost of war and an increasing focus on military spending by national governments, often at the expense of international aid budgets, particularly in the UK, Europe and the USA.^26,27 This has resulted in a reduction in opportunities to pursue international collaborative research and educational initiatives. Meanwhile, political decision-makers in the USA are seeking to actively undermine and erode international collaborations.²⁸ It is therefore commendable that the VSGBI has chosen this moment to engage in activities which strengthen global health collaborations.

Conclusion

This Subcommittee will bring together those who are interested in vascular surgery provision in a global context for educational, research and advocacy purposes. It will collaborate internationally in a way which is long-term rather than episodic, bidirectional rather than extractive and, wherever possible, locally led in priority and direction setting. We therefore invite readers with existing global health projects, partnerships or educational commitments to become part of our community of practice, so that we can map projects and connect individuals. We call on trainees and consultants who wish to contribute in this field to express an interest, and for colleagues based at, or with links to, organisations in other countries and regions to tell us what would be most useful to them. For this initiative to flourish, we need your support and engagement. Further details on how you can get involved will be available on the VSGBI website soon.