Defining humanitarian surgery: international consensus in global surgery

Introduction

Global health has been described as one of the defining issues of our time¹. Despite widespread attention on global health since the 1980s, it was not until 2009 that Koplan et al.² offered a common definition of the term. Agreeing on a definition ensured clarity on the aims, on how to achieve them, and the skills and resources required. More recently, Dare et al.¹ offered the following widely used definition of global surgery: ‘an area of study, research, practice, and advocacy that seeks to improve health outcomes and achieve health equity for all people who require surgical care, with a special emphasis on underserved populations and populations in crisis’. This definition includes both underserved populations and populations in crisis, but did not define crises in the context of humanitarian medicine³.

Frequently the term ‘humanitarian surgery’ is used to broadly describe surgical work undertaken for underserved populations, for example in charitable or disease-specific surgical missions, as well as disaster responses for populations in crisis^4,5. Indeed, there have been over 45 different terms to describe short-term charitable surgical missions^6–9. Without a clear definition of humanitarian surgery, it is difficult to interpret published data and analyses⁶. The lack of clarity and standardization was particularly apparent in the response to the 2010 Haiti earthquake where widespread concerns were raised about the variable capability and the quality of care provided by some organizations^10,11. In an effort to move towards more professional delivery of care, the WHO developed the Emergency Medical Team (EMT) minimal technical standards (known as the ‘Blue Book’) and specific guidance for teams deploying into armed conflicts—the ‘Red Book’^12–14. Clarity on the terminology will help to identify the capabilities, experience, and qualifications required for teams and individuals to effectively deliver care in these very demanding environments. The authors present an international consensus drawn from experts in the fields of global surgery, conflict, and disaster response to define the term humanitarian surgery.

Methods

An online Delphi process was conducted and reported following the Standards for Reporting Qualitative Research (SRQR) guidelines—see Table S1¹⁵. Dedicated online software was used (Welphi, Lisbon, Portugal). Ethical review and approval was provided by the London School of Economics and Political Science (reference: 91957). Research was conducted in accordance with the principles of the Declaration of Helsinki¹⁶. Data were exported to Microsoft^® Excel (Microsoft, Redmond, WA, USA; Version 16.67) for analysis and statistical analysis was conducted using SPSS^® (IBM, Armonk, NY, USA; Version 27).

A broad, international, multidisciplinary group of stakeholders was identified through a literature review, personal contacts of the authors, and the Global Affairs Department of the Royal College of Surgeons of England (RCS England). In total, 157 respondents were invited to participate via e-mail and encouraged to invite colleagues who also met the inclusion criteria—see Table S2 for full demographics and Table S3 for the list of respondents. Snowball sampling was used through e-mails and social media channels to widen participation. The inclusion criteria used were: age greater than 18 years; ability to speak, read, or write any of the six official languages of the United Nations (English, French, Spanish, Arabic, Russian, and Chinese; and at least one of the following: active in humanitarian or global surgery/medicine/research/healthcare development or provision (within the past 5 years); currently (within the past 12 months) affiliated with an organization involved in global and/or humanitarian surgery; a patient or public representative with experience of a sudden-onset disaster; or a healthcare worker who works primarily in a low- or middle-income country.

Public involvement was carried out in accordance with the Guidance for Reporting Invovlement of Patients and the Public 2 - Short Form (GRIPP2-SF) framework and aimed to ensure that the voices of those who may receive humanitarian surgical care were represented—see Table S4¹⁷.

The Delphi process was held over three rounds, followed by a definition workshop to agree on the final wording. Round 1 invited 10 global health researchers affiliated with the RCS England to an online focus group to answer the question ‘What is humanitarian surgery?’; this same question was published on the RCS England’s social media accounts. The responses were collected and analysed thematically to generate 25 separate statements. In rounds 2 and 3, respondents were asked to vote on their agreement with each of these statements using a seven-option Likert scale. In round 3, respondents were shown their previous response and the group median before voting. Further detail on the methodology can be found in the Supplementary Methods.

Agreement refers to the individual participant agreeing with a statement; this then provides group opinion, or central tendency, and can be measured by the group mean or median.

Consensus refers to the extent to which participants agree with each other; this is measured by the interquartile range (i.q.r.)¹⁸.

Median and i.q.r. were selected as they are generally considered more robust than mean and standard deviation¹⁹. A group median of greater than 4 was decided as the group agreeing with the statement. Consensus was determined using i.q.r. to assess the variance of response; an i.q.r. of less than 2 was chosen as a cut-off to indicate group consensus.

Results

In total, 147 responses were recorded. After exclusions, 107 responses were recorded in round 2 and 65 responses were recorded in round 3—see Fig. 1 for an overview. Responses came from 6 countries in round 1, 34 countries in round 2, 27 countries in round 3; and 8 countries in the definition workshop (see Table 1).

Fig. 1

Schematic overview of Delphi process

Table 1

Number of participants by country of practice

Country of practice (income classification)	Round 1	Round 2	Round 3	Definition workshop
UK (high)	3	29	24	5
Yemen (low)	1	22	7	1
Kenya (lower middle)	1	5	1	1
India (lower middle)	–	4	3	–
Sierra Leone (low)	–	3	1	–
Palestinian National Authority (lower middle)	1	3	3	1
Syria (low)	–	3	1	–
Cameroon (lower middle)	1	3	1	2
Egypt (lower middle)	1	3	2	1
Australia (high)	–	2	1	–
Sri Lanka (lower middle)	–	2	2	–
Nigeria (lower middle)	–	2	2	–
Lebanon (lower middle)	–	2	1	–
Somalia (low)	–	1	–	–
USA (high)	–	1	1	1
Benin (lower middle)	–	1	–	–
Ireland (high)	–	1	1	–
Japan (high)	–	1	1	–
Ethiopia (low)	–	1	–	1
Jordan (upper middle)	–	1	1	–
United Arab Emirates (high)	–	1	1	–
Colombia (upper middle)	–	1	–	–
China (upper middle)	–	1	1	–
Libya (upper middle)	–	1	1	–
Spain (high)	–	1	1	–
Sudan (low)	–	1	–	–
Nepal (lower middle)	–	1	1	–
Uganda (low)	–	1	1	–
Democratic Republic of the Congo (low)	–	1	1	–
Norway (high)	–	1	–	–
Greece (high)	–	1	1	–
Brazil (upper middle)	–	1	1	–
Qatar (high)	–	1	1	–
Global	2	4	2	9
Total	10	107	65	2

During round 1, 50% (5) of responses came from respondents based in low- or middle- income countries; this was 53% (57) in round 2, 42% (27) in round 3, and 73% (16) in the definition workshop. A full breakdown of the demographics can be found in Table S2.

Statements

Round 1 generated 25 statements, these were separated into four themes: Who should deliver humanitarian surgical care?; What care should be delivered?; Where should humanitarian surgery be delivered?; and When should humanitarian surgery be delivered?

Of these statements, 10 reached agreement and consensus in round 2, all of which met agreement and consensus in round 3 (Table 2). For each of the 10 agreed statements, the median was either stable or increasing and the i.q.r. was either stable or narrowing, indicating a high degree of both agreement and consensus.

Table 2

The 10 statements that reached agreement and consensus after two rounds of voting

No.	Theme	Statement	Median (trend)	Interquartile range (trend)
1	Who	Delivered by a multidisciplinary team of surgeons, anaesthesia providers, nurses, and other healthcare professionals, including, where practical, pharmacists, laboratory technicians, and specialists in policy, logistics, and security	4 (stable)	1 (stable)
2	Who	Delivered in coordination with the local health system and the local government	4.5 (increasing)	1 (stable)
3	What	Humanitarian surgery should be delivered in line with the humanitarian principles (humanity, neutrality, impartiality, and independence)	5 (increasing)	0 (narrowing)
4	What	Humanitarian surgery includes emergency adult and paediatric, surgical, anaesthetic, obstetric, and trauma care	5 (increasing)	0 (narrowing)
5	What	Humanitarian surgery should include preoperative, intraoperative, and postoperative care, and follow-up, although these may not all be with the same provider	5 (stable)	1 (stable)
6	What	Humanitarian surgery should collect standardized data for clinical governance	4.5 (stable)	1 (stable)
7	What	Humanitarian surgery should use standardized protocols or guidelines for care, although these may need to be tailored to the individual circumstance	4 (stable)	1 (narrowing)
8	Where	In conflict and post-conflict zones	5 (stable)	1 (stable)
9	Where	In areas of sudden-onset disasters	5 (increasing)	0 (stable)
10	When	When the local health system is, or is at risk of, being overwhelmed	4.5 (increasing)	1 (stable)

Italic text corresponds to text added after feedback from round 2.

The final 10 statements are presented in Table 2 along with the respective median and i.q.r. The trend of the median and i.q.r. across rounds 2 and 3 is shown in brackets after the values. The full list of the 15 statements that did not reach agreement can be seen in Table 3.

Table 3

The 15 statements that did not reach either agreement or consensus after round 1

No.	Theme	Statement	Median	Interquartile range
11	Who	Relies on international and intersectional collaboration	3.5	2
12	What	Humanitarian surgery is a sub-specialty of ‘global surgery’	3.5	2
13	What	The term humanitarian surgery is interchangeable with global surgery	3.5	3
14	What	Humanitarian surgery should build local capacity	3.5	1
15	What	Humanitarian surgery should provide preventative care such as contraception	3.5	2
16	What	Humanitarian surgery should provide rehabilitation	3.5	2
17	What	Humanitarian surgery should provide palliative care	3.5	1
18	What	Humanitarian surgery should provide non-emergency care such as elective hernia repair	3.5	3
19	What	Humanitarian surgery is not primarily intended to resolve the crisis but provide essential care	3.5	1
20	What	Humanitarian surgery should provide education, research, and/or advocacy expertise in addition to a clinical role	3.5	1
21	Where	Where there are failed or failing health systems	3.5	1
22	Where	Wherever it takes place, humanitarian surgery should be adapted to the local context, both in terms of human and material resources	3.5	1
23	When	For a defined interval of time	3.5	1
24	When	When invited by the local population or local government	3.5	2
25	When	Is a temporary necessity	3.5	1

Full definition

Using the statements agreed within this study, the authors propose the following definition of humanitarian surgery. Humanitarian surgery is an area for study, research, and practice that focuses on surgical care in conflict and post-conflict zones, in areas of sudden-onset disasters, and when the local health system is overwhelmed. Emergency surgical care, including anaesthesia, should be provided to patients of all ages. Perioperative and follow-up care should be provided, although these may not be provided by the same clinician. Care should be delivered in line with the core humanitarian principles (humanity, neutrality, impartiality, and independence) and, wherever possible, in coordination with the local health system and government. Humanitarian surgery is a multidisciplinary field involving surgical and anaesthetic providers, nurses, rehabilitation specialists, and other healthcare professionals, including pharmacists, laboratory technicians, and specialists in policy, logistics, and security. Standardized data should be collected and standardized protocols or guidelines should be used, although these should be tailored to the individual circumstance.

Working definition

As the above definition is extensive, the authors have followed the example of Dare et al.¹ and propose the following shorter working definition of humanitarian surgery. Humanitarian surgery is an area for study, research, and practice that focuses on the coordinated provision of emergency surgical care, in accordance with the humanitarian principles, in conflict and post-conflict zones, in areas of sudden-onset disasters, and when the local health system is overwhelmed.

Discussion

Defining the term humanitarian surgery has a number of benefits. First, it will allow comparison of humanitarian surgical activities against agreed standards^20–22. Agreeing what ‘is’ considered humanitarian surgery also allows clarity on what should ‘not’ be considered humanitarian surgery. The current use of confusing and often contradictory terms prevents meaningful evaluation and quality assurance. Clarity about what is, and what should not be, considered as humanitarian surgery will allow more meaningful collection and comparison of data.

Second, agreeing on the definition helps move the discussion towards addressing diverse ethical and logistical challenges regarding the scope and the remit of humanitarian surgery. Key questions also need to be addressed: When should teams be deployed?; For how long should they deploy?; How, and when, do these teams handover to local health systems appropriately and safely?; and What are reasonable expectations from humanitarian surgical care and how should they be communicated to patients and the local health system? Attempting to answer these questions will be complex and may raise difficult practical or ethical dilemmas. Future work should focus on other qualitative research methods to explore key concepts in more depth.

The authors’ definition of humanitarian surgery provides a framework that will allow more robust comparison of activities and encourage professional training. Humanitarian crises are complex situations, fraught with danger, and mistakes can have far-reaching and severe consequences for patients, communities, providers, and local health systems^11,23,24. The teams who deploy into them must be suitably trained and experienced to provide a high standard of care for vulnerable populations.

Conflict and sudden-onset disasters have both been included in the authors’ definition of humanitarian surgery. The determinants of conflict are dynamic and complex, and can be exacerbated by the effect of sudden-onset disasters, climate change, and urbanization^25,26. Thus, making a distinction between humanitarian crises due to armed conflict or any other causes is unhelpful. Whilst the response to any crisis must be tailored to the individual situation, humanitarian surgical teams will be expected to respond to a wide variety of crises.

The motivation of individuals, organizations, and funders to provide humanitarian surgery has not been addressed in this article. The reasons why an individual may offer their services (either with or without payment) to provide humanitarian surgery are complex and have been assessed elsewhere^27–31.

The scope of humanitarian surgery remains contentious. Statements suggesting that humanitarian surgery should build local capacity and include rehabilitation and palliative care failed to reach agreement. It is important to note that both rehabilitation and palliative care form an essential part of both the WHO EMT 2020 consensus framework and The Sphere Handbook minimum standards^13,21,22. Thus, although not included in the consensus definition provided here, access to these services should be considered part of the continuum of care for surgical patients in humanitarian settings. Importantly, a review of the WHO-led trauma system set-up during the battle of Mosul identified that ‘post-operative and rehabilitative care could have been anticipated sooner and better incorporated into planning’³².

It is also important to note that the WHO EMT programme calls for all member states to develop national EMTs and this work should be strongly supported as part of the wider effort to ‘decolonize’ humanitarian aid through reducing the dependence on EMTs and Non-Governental Organisations (NGOs) based mainly in Europe and North America.

Despite the efforts made to ensure a representative group of respondents, surgeons were over-represented and this may have narrowed the scope of this Delphi study. However, there was a broad mix of respondents from a wide variety of disciplines. Additionally, there were no responses from non-physician clinicians such as Community Health Officers who provide a significant proportion of surgical care in many regions across the world; capturing their views should be the focus of further work in this area.

As in any qualitative research, there is bias within this study. The areas of highest responses were countries where the RCS England’s Humanitarian Surgery Initiative (HSI) Fellows are based. The five Fellows based outside of the UK are primarily clinicians in their local health system and working part-time for the RCS England. This ensures that the voices of those working in low- and middle-income countries have been expressed, whilst ensuring that their time is appropriately remunerated. Additionally, all HSI Fellows undertook a funded research methods e-learning module to ensure a lasting benefit to research capacity within their health systems, see Table S5 for authorship reflexivity.

The UK was the country with the highest number of responses, which may also overemphasize a high-income country or donor perspective. However, overall, there was good geographical representation in each round of the study and at least 50% of responses were from low- or middle-income countries. Accessing patient or public representatives from low- or middle-income countries proved difficult. Although based in the UK, the patient representative did have direct experience of a sudden-onset disaster and gave a unique insight.

The dropout rate in-between rounds 2 and 3 was higher than expected. This is likely to be due to extending the initial data collection interval. This extension was decided to encourage greater participation from low- and middle-income countries. This did lead to significantly more responses from low- and middle-income countries, but likely at the cost of a higher attrition rate between rounds.

This is the first published study to agree on a definition of humanitarian surgery. This will help facilitate high-quality humanitarian surgical care and will provoke further debate and research in this area.

Funding

The research has been conducted with the support of the UK Humanitarian Innovation Hub and the donor, the UK Foreign, Commonwealth & Development Office. The views expressed do not necessarily reflect the UK Government's official policies.

Acknowledgements

The authors would like to thank Dr Michal Tombs for her assistance in the methodological and data analysis aspects of this study.

Author contributions

Gerard H. O. McKnight (Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Writing—original draft, Writing—review & editing), Rocco Friebel (Conceptualization, Methodology, Supervision, Writing—review & editing), Isobel Marks (Conceptualization, Methodology, Writing—review & editing), Ahmed Almaqadma (Conceptualization, Methodology, Writing—review & editing), Mohamed Youssef Seleem (Conceptualization, Methodology, Writing—review & editing), Tim Fabrice Tientcheu (Conceptualization, Methodology, Writing—review & editing), Raoof Saleh (Conceptualization, Methodology, Writing—review & editing), Marcella Ryan-Coker (Conceptualization, Methodology, Writing—review & editing), Rosemary Emodi (Funding acquisition, Project administration, Resources, Writing—review & editing), Mai Seida (Project administration, Writing—review & editing), Jonathan Barden (Conceptualization, Methodology, Writing—review & editing), Anthony Redmond (Writing—review & editing), Mohana Amirtharajah (Conceptualization, Methodology, Supervision, Writing—review & editing), Sherry M. Wren (Conceptualization, Methodology, Supervision, Writing—review & editing), Andrew Leather (Writing—review & editing), and Rachel Hargest (Conceptualization, Methodology, Supervision, Writing—original draft, Writing—review & editing)

Disclosure

The authors declare no conflict of interest.

Supplementary material

Supplementary material is available at BJS online.

Data availability

All data collected are available on request by e-mailing the corresponding author.

References