Making Surgery Work in the Places that Need it Most

Marred by political and ethnic conflicts that have raged for more than a decade, the Nuba Mountains in Sudan may be among the most challenging places on Earth to offer surgical care. At Mother of Mercy Hospital, one of just two health facilities that serve a region the size of Austria, there is only one doctor trained to perform most surgeries, and staff deal with constant supply shortages and occasional shelling from the Sudanese military.

But the surgeries performed at the hospital aren’t just acts of medical bravery. According to a new economic analysis of the hospital’s surgical care, they are also remarkably cost-effective, offering rare evidence of the benefits of providing surgery in places affected by war and conflict.

The study, published in the journal PLOS Global Health, assessed the costs and economic benefits of more than 3,000 surgical procedures performed during 2022 at the remote hospital in southern Sudan. It found that the surgeries generated more than $10 million of economic and social benefits for the war-torn region, a more than 14-fold return on investment that compares favorably with the cost-effectiveness of public health interventions such as providing bed nets to prevent malaria or antiretroviral therapies for HIV.

While many studies have shown surgery to be a cost-effective investment for health systems, the new analysis is one of the few to examine its economic value in a conflict zone, says Henry Rice, M.D., co-director of the Center for Global Surgery and Health Equity at the Duke Global Health Institute, who coordinated the research.

“What we’ve seen in the conflicts in Sudan and Gaza is that the resources for surgery are often diverted to more urgent needs,” says Rice, a pediatric surgeon and professor of global health at Duke. “This shows that not only is it possible to support surgical systems in areas of armed conflict, but that it can be done very efficiently and effectively.”

A quarter of the world’s population resides in countries impacted by conflict, according to the United Nations –  the largest number of people living in harm’s way since World War II. While wars impact all aspects of health care, their disruption of services such as surgery, which are already rare in many low- and middle-income countries, can deepen the long-term suffering of communities scarred by conflict.

The new research focused on Mother of Mercy Hospital in part because it defies that trend. Launched in 2008 by Tom Catena, M.D., an alumnus of the Duke School of Medicine, the 425-bed facility consistently has offered a range of surgical services in an isolated region of southern Sudan that has been marked by cycles of conflict since 2011. The hospital serves a population of nearly 2 million people, many of whom have been displaced by the ongoing war.

Catena performs many of the surgeries, including obstetrical procedures, laparotomies and repairs of open fractures. Other providers at the hospital are trained to do cataract and dental surgeries. Patients pay some expenses if they are able, but the hospital’s budget, which comes mostly from philanthropic donations, fills in for those who can’t afford care.

The researchers determined the cost-benefit of the hospital’s surgeries by assessing the probability of a patient dying prematurely or being permanently disabled if surgery were not performed, a standard way to measure the value of medical interventions. Their calculation of a 14-to-1 return on investment exceeds what has been measured in studies of surgery in politically stable settings, Rice notes.

It’s a unique facility in that they are able to provide these services at a very low cost,” says Rice. “What we’re able to show is that the investment they have made in surgery is a very worthy investment, even despite the challenges.”

Although the study reflects the success of a single hospital, Rice says it offers a model for showing the tangible benefits of maintaining resilient health systems in places affected by conflict.  While there are strong moral and humanitarian arguments to support healthcare in conflict-affected areas, an economic analysis can document the kinds of bottom-line impacts that often drive resource decisions by donors or governments, he notes.

“The sad fact is that over half of the world’s children live in areas affected by armed conflict,” He says, “And so we’re going to have to get better at understanding how to deliver care in ways that are efficient and cost-effective in those settings.”

Catena and staff at Mother of Mercy Hospital collaborated on the research, along with public health scholars at Harvard University and African Mission Healthcare, a Kenyan foundation that supports mission hospitals across Africa. Emily Smith, Ph.D., an assistant professor of emergency medicine and global health at Duke, co-authored the study.