Starting a spine surgery service in a low-resource setting: a look back over twenty five years of spine surgery in Malawi.

PURPOSE: This is a short historical narrative of the development of spine surgery in Malawi. METHODS: The authors communicated and both drew on memories and anecdotes over the last 25 years. RESULTS: This is not a scientific paper, so there are no results. CONCLUSION: The short paper outlines the development of spine surgery in Malawi over the last 25 years. This develops in association with the overall increase in the number of surgeons in the country.

Post-void bladder ultrasound in suspected cauda equina syndrome-data from medicolegal cases and relevance to magnetic resonance imaging scanning.

OBJECTIVE: Post-void residual (PVR) scans of less than 200 ml are increasingly being used to rule out the likelihood of cauda equina syndrome (CES) and to delay emergency MRI scanning in suspected cases. This study was done to review a series of 50 MRI confirmed cases of CES and to test the hypothesis that a PVR of less than 200 ml was unlikely to be present. METHODS: Fifty consecutive medicolegal cases involving CES were audited. Records were reviewed to see if PVR scans were done. MRI scans were reviewed, clinical and radiological diagnosis reviewed, and treatment recorded. RESULTS: Out of 50 CES cases, 26 had had PVR scans. In 14/26 (54%) the PVR scan was ≤ 200 ml. In one case, the CES diagnosis was in question leaving 13/26 (50%) cases where there was a clear clinical and MRI diagnosis of CES despite the PVR being ≤ 200 ml. All 13 were classified as incomplete cauda equina syndrome (CESI) and all proceeded to emergency decompression. CONCLUSIONS: This study is the first in the literature to demonstrate that there is a significant group of CES patients who require emergency decompression but have PVRs ≤ 200 ml. The results demonstrate the existence of a significant group of CESI patients whose bladder function may be deteriorating, but they have not yet reached the point where the PVR is over 200 ml. Given the accepted understanding that CESI is best treated with emergency decompression, such patients are likely to have worse outcomes if MRI scanning and therefore surgery is delayed. We recommend the following: PVR is recommended as an assessment tool in suspected CES. A PVR of ≤ 200 reduces the likelihood of having CES but does not exclude it; clinical suspicion of CES should always lead to an MRI scan. Further investigation of PVR as a prognostic tool is recommended.

Cauda equina syndrome-a practical guide to definition and classification.

PURPOSE: International uniformity of definition and classification are crucial for diagnosis and management of cauda equina syndrome (CES). They are also useful for clinicians when discussing CES with patients and relatives, and for medicolegal purposes. METHODS: We reviewed published literature using PubMed on definition and classification of cauda equina syndrome since 2000 (21 years). Using the search terms 'cauda equina' and 'definition' or 'classification', we found and reviewed 212 papers. RESULTS: There were 17 different definitions of CES used in the literature. There were three well-defined methods of classification of CES. The two-stage system of incomplete CES (CESI) versus CES with retention (CESR) is the most commonly used classification, and has prognostic value although the details of this continue to be debated. CONCLUSION: We used the existing literature to propose a clear definition of CES. We also drew on peer-reviewed published literature that has helped to amplify and expand the CESI/CESR dichotomy, adding categories that are both less severe than CESI, and more severe than CESR, and we propose clear definitions in a table form to assist current and future discussion and management of CES.

Which Surgical Operations Should be Performed in District Hospitals in East, Central and Southern Africa? Results of a Survey of Regional Clinicians.

BACKGROUND: In East, Central and Southern Africa (ECSA), district hospitals (DH) are the main source of surgical care for 80% of the population. DHs in Africa must provide basic life-saving procedures, but the extent to which they can offer other general and emergency surgery is debated. Our paper contributes to this debate through analysis and discussion of regional surgical care providers' perspectives. METHODS: We conducted a survey at the College of Surgeons of East, Central and Southern Africa Conference in Kigali in December 2018. The survey presented the participants with 59 surgical and anaesthesia procedures and asked them if they thought the procedure should be done in a district level hospital in their region. We then measured the level of positive agreement (LPA) for each procedure and conducted sub-analysis by cadre and level of experience. RESULTS: We had 100 respondents of which 94 were from ECSA. Eighteen procedures had an LPA of 80% or above, among which appendicectomy (98%), caesarean section (97%) and spinal anaesthesia (97%). Twenty-one procedures had an LPA between 31 and 79%. The surgical procedures that fell in this category were a mix of obstetrics, general surgery and orthopaedics. Twenty procedures had an LPA below 30% among which paediatric anaesthesia and surgery. CONCLUSION: Our study offers the perspectives of almost 100 surgical care providers from ECSA on which surgical and anaesthesia procedures should be provided in district hospitals. This might help in planning surgical care training and delivery in these hospitals.

Childhood musculoskeletal impairment in Malawi from traumatic and non-traumatic causes: a population- based assessment using the key informant method.

BACKGROUND: Musculoskeletal impairment (MSI) in children is an under-recognised public health challenge. Although preventable, road injuries and other traumas continue to cause significant impairments to children worldwide. The study aimed to use the Key Informant Method (KIM) to assess prevalence and causes of MSI in children in two districts in Malawi, estimating the associated need for services provision, with a focus on traumatic aetiology. METHODS: The KIM was conducted in the districts of Thyolo (Southern Malawi) and Ntcheu (Central Malawi) in 2013. Five hundred key informants were trained to identify children who may have one of a range of MSI. The identified children were referred to a screening camp where they were examined by medical experts with standardised assessment protocols for diagnosing each form of impairment. RESULTS: 15,000 children were referred to screening camps. 7220 children were assessed (response rate 48%) for an impairment of whom 15.2% (1094) had an MSI. 13% of children developed MSI from trauma, while 54% had a neurological aetiology. For MSI of traumatic origin the most common body part affected was the elbow. Less than half of children with MSI (44.4%) were enrolled in school and none of these children attended schools with resources for disability. More than half of children with MSI (60%) had not received required services and 64% required further physical therapy. CONCLUSIONS: The KIM method was used to identify a high prevalence of MSI among children in two districts of Malawi and estimates an unmet need for dedicated MSI services.

Exploring the Impact of COVID-19 on Progress Towards Achieving Global Surgery Goals.

INTRODUCTION: In the 5 months since it began, the COVID-19 pandemic has placed extraordinary demands on health systems around the world including surgery. Competing health objectives and resource redeployment threaten to retard the scale-up of surgical services in low- and middle-income countries where access to safe, affordable and timely care is low. The key aspiration of the Lancet Commission on global surgery was promotion of resilience in surgical systems. The current pandemic provides an opportunity to stress-test those systems and identify fault-lines that may not be easily apparent outside of times of crisis. METHODS: We endeavoured to explore vulnerable points in surgical systems learning from the experience of past outbreaks, using examples from the current pandemic, and make recommendations for future health emergencies. The 6-component framework for surgical systems planning was used to categorise the effects of COVID-19 on surgical systems, with a particular focus on low- and middle-income countries. Key vulnerabilities were identified and recommendations were made for the current pandemic and for the future. RESULTS: Multiple stress points were identified throughout all of the 6 components of surgical systems. The impact is expected to be highest in the workforce, service delivery and infrastructure domains. Innovative new technologies should be employed to allow consistent, high-quality surgical care to continue even in times of crisis. CONCLUSIONS: If robust progress towards global surgery goals for 2030 is to continue, the stress points identified should be reinforced. An ongoing process of reappraisal and fortification will keep surgical systems in low- and middle-income countries responsive to "old threats and new challenges". Multiple opportunities exist to help realise the dream of surgical systems resilient to external shocks.

Identifying New Frontiers for Social Media Engagement in Global Surgery: An Observational Study.

BACKGROUND: The purpose of this observational study is to characterize the use of social media content pertaining to global surgery. METHODS: A search for public posts on social media related to global surgery was performed over a 3-month window, from January 1st, 2019, to March 31st, 2019. Two public domains were included in the search: Instagram and Twitter. Posts were selected by filtering for one hashtag: #GlobalSurgery. A binary scoring system was used for media format, perspective of the poster, timing of the post, tone, and post content. Data were analyzed using Chi-squared tests with significance set to p < 0.05. RESULTS: Overall, 2633 posts with the hashtag #GlobalSurgery were publicly shared on these two social media platforms over the 3-month period. Of these, 2272 (86.3%) referenced content related to global surgery and were original posts. Physicians and other health professionals authored a majority (60.5%, 1083/1788) of posts on Twitter, whereas organizations comprised a majority of the posts on Instagram (59.9%, 290/484). Posts either had a positive (50.2%, 1140/2272) or neutral (49.6%, 1126/2272) tone, with only 0.3% or 6/2272 of posts being explicitly negative. The content of the posts varied, but most frequently (43.4%, 986/2272) focused on promoting communication and engagement within the community, followed by educational content (21.3%, 486/2272), advertisements (18.8%, 427/2272), and published research (13.2%, 299/2272). The majority of global surgery posts originated from the USA, UK, or Canada (67.6%, 1537/2272), followed by international organizations (11.5%, 261/2272). Chi-squared analysis comparing Instagram with Twitter performed examining media content, tone, perspective, and content, finding statistically significant differences (p < 0.001) the two platforms for each of the categories. CONCLUSION: The online social media community with respect to global surgery engagement is predominantly composed of surgeons and health care professionals, focused primarily on promoting dialogue within the online community. Social media platforms may provide a scalable tool that can augment engagement between global surgeons, with remaining opportunity to foster global collaboration, community engagement, education and awareness.

Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania, and Zambia: A Mixed-Methods Study.

BACKGROUND: District-level hospitals (DLHs) are the main providers of surgical services for rural populations in Sub-Saharan Africa (SSA). Skilled teams are essential for surgical care, and gaps in anesthesia impact negatively on surgical capacity and outcomes. This study, from a baseline of a project scaling-up access to safe surgical and anesthesia care in Malawi, Tanzania, and Zambia, illustrates the deficit of anesthesia care in DLHs. METHODS: We undertook an in-depth investigation of anesthesia capacity in 76 DLHs across the 3 countries, July to November 2017, using a mixed-methods approach. The quantitative component assessed district-level anesthesia capacity using a standardized scoring system based on an adapted and extended Personnel, Infrastructure, Procedures, Equipment and Supplies (PIPES) Index. The qualitative component involved semistructured interviews with providers from 33 DLHs, exploring how weaknesses in anesthesia impacted district surgical team practices and quality, volume, and scope of service provision. RESULTS: Anesthesia care at the district level in these countries is provided only by nonphysician anesthetists, some of whom have no formal training. Ketamine anesthesia is widely used in all hospitals, compensating for shortages of other forms of anesthesia. Pediatric size supplies/equipment were frequently missing. Anesthesia PIPES index scores in Malawi (M = 8.0), Zambia (M = 8.3), and Tanzania (M = 8.4) were similar (P = .59), but an analysis of individual PIPES components revealed important cross-country differences. Irregular availability of reliable equipment and supply is a particular priority in Malawi, where only 29% of facilities have uninterrupted access to electricity and 23% have constant access to water, among other challenges. Zambia is mostly affected by staffing shortages, with 30% of surveyed hospitals lacking an anesthesia provider. The challenge that stood out in Tanzania was nonavailability of functioning anesthesia machines among frequent shortages of staff and other equipment. CONCLUSIONS: Tanzania, Malawi, and Zambia are falling far short of ensuring universal access to safe and affordable surgical and anesthesia care for district and rural populations. Mixed-methods situation analyses, undertaken in collaboration with anesthesia specialists-measuring and understanding deficits in district hospital anesthetic staff, equipment, and supplies-are needed to address the critical neglect of anesthesia that is essential to providing surgical responses to the needs of rural populations in SSA.

Correction to: Childhood disability in Malawi: a population based assessment using the key informant method.

Following the publication of this article [1] it was brought to our attention that inadvertently the COSECSA Oxford Orthopaedic Link (COOL) programme was not acknowledged for funding this study.

Childhood disability in Malawi: a population based assessment using the key informant method.

BACKGROUND: Epidemiological data on childhood disability are lacking in Low and Middle Income countries (LMICs) such as Malawi, hampering effective service planning and advocacy. The Key Informant Method (KIM) is an innovative, cost-effective method for generating population data on the prevalence and causes of impairment in children. The aim of this study was to use the Key Informant Method to estimate the prevalence of moderate/severe, hearing, vision and physical impairments, intellectual impairments and epilepsy in children in two districts in Malawi and to estimate the associated need for rehabilitation and other services. METHODS: Five hundred key informants (KIs) were trained to identify children in their communities who may have the impairment types included in this study. Identified children were invited to attend a screening camp where they underwent assessment by medical professionals for moderate/severe hearing, vision and physical impairments, intellectual impairments and epilepsy. RESULTS: Approximately 15,000 children were identified by KIs as potentially having an impairment of whom 7220 (48%) attended a screening camp. The estimated prevalence of impairments/epilepsy was 17.3/1000 children (95% CI: 16.9-17.7). Physical impairment (39%) was the commonest impairment type followed by hearing impairment (27%), intellectual impairment (26%), epilepsy (22%) and vision impairment (4%). Approximately 2100 children per million population could benefit from physiotherapy and occupational therapy and 300 per million are in need of a wheelchair. An estimated 1800 children per million population have hearing impairment caused by conditions that could be prevented or treated through basic primary ear care. Corneal opacity was the leading cause of vision impairment. Only 50% of children with suspected epilepsy were receiving medication. The majority (73%) of children were attending school, but attendance varied by impairment type and was lowest among children with multiple impairments (38%). CONCLUSION: Using the KIM this study identified more than 2500 children with impairments in two districts of Malawi. As well as providing data on child disability, rehabilitation and referral service needs which can be used to plan and advocate for appropriate services and interventions, this method study also has an important capacity building and disability awareness raising component.

Prioritisation of surgery in the National Health Strategic Plans of Africa: a systematic review.

BACKGROUND: Disease amenable to surgical intervention accounts for 11-15% of world disability and there is increasing interest in surgery as a global public health issue. National Health Strategic Plans (NHSPs) have been established in most countries and reflect their long-term health priorities, plans, and targets. To assess surgery's perceived importance in Africa, we reviewed its place in all such available plans. METHODS: We analysed all 43 of the 55 independent countries in Africa that had NHSPs available in the public domain in March, 2014, in English or French. We searched for policies electronically with the search terms "surg*", "ortho*", "trauma", "cancer", "appendic*", "laparotomy", "HIV", "tuberculosis", and "malaria" and included those from 2002 to 2030. We then searched manually for disease prevalence, targets, and human resources. FINDINGS: Eight (19%)of 43 NHSPs had no mention of surgery or surgical conditions. 28 (65%) of 43 had five or less mentions of surgery. HIV and malaria had 3801 mentions across all the policies compared with surgery with only 379 mentions. Trauma had 243 mentions, while the common surgical conditions of appendicitis, laparotomy, and hernia had no mentions at all. More than 95% (41 of 43) of NHSPs specifically mentioned the prevalences of HIV, tuberculosis, malaria, infant mortality, and maternal mortality. The most commonly mentioned surgical condition for which a prevalence was given was trauma, in only 47% (23 of 43) of policies. All NHSPs had plans and measurable targets for the reduction of HIV and tuberculosis and all but one had targets for malaria, maternal mortality, and child mortality. Of the 4232 health targets across 43 NHSPs, only 96 (2·3%) were related to surgical conditions or surgical care. 14 (33%) of 43 policies had no surgical targets. INTERPRETATION: NHSPs are the best available measure of health service and planning priorities. It is clear from our findings that surgery is poorly represented and that surgical conditions and surgical treatment are not widely recognised as a public health priority. A paradigm shift is required if surgery is to be considered a public health concern, which should include greater prioritisation in national health strategic policies. FUNDING: None.

Prioritisation of Surgery in the National Health Strategic Plans of Africa: A Systematic Review.

INTRODUCTION: Disease amenable to surgical intervention accounts for 11-15 % of world disability and there is increasing interest in surgery as a global public health issue. National Health Strategic Plans (NHSPs) reflect countries' long-term health priorities, plans and targets. These plans were analysed to assess the prioritisation of surgery as a public health issue in Africa. METHODS: NHSPs of 43 independent Sub-Saharan African countries available in the public domain in March 2014 in French or English were searched electronically for key terms: surg*, ortho*, trauma, cancer, appendic*, laparotomy, HIV, tuberculosis, malaria. They were then searched manually for disease prevalence, targets, and human resources. RESULTS: 19 % of NHSPs had no mention of surgery or surgical conditions. 63 % had five or less mentions of surgery. HIV and malaria had 3772 mentions across all the policies, compared to surgery with only 376 mentions. Trauma had 239 mentions, while the common surgical conditions of appendicitis, laparotomy and hernia had no mentions at all. Over 95 % of NHSPs specifically mentioned the prevalence of HIV, tuberculosis, malaria, infant mortality and maternal mortality. Whereas, the most commonly mentioned surgical condition for which a prevalence was given was trauma, in only 47 % of policies. All NHSPs had plans and measurable targets for the reduction of HIV and tuberculosis. Of the total 4064 health targets, only 2 % were related to surgical conditions or surgical care. 33 % of policies had no surgical targets. DISCUSSION: NHSPs are the best available measure of health service and planning priorities. It is clear from our findings that surgery is poorly represented and that surgical conditions and surgical treatment are not widely recognised as a public health priority. Greater prioritisation of surgery in national health strategic policies is required to build resilient surgical systems.

Systematic Review of Surgical Literature from Resource-Limited Countries: Developing Strategies for Success.

BACKGROUND: Injuries and surgical diseases are leading causes of global mortality. We sought to identify successful strategies to augment surgical capacity and research endeavors in low-income countries (LIC's) based on existing peer-reviewed literature. METHODS: A systematic review of literature from or pertaining to LIC's from January 2002 to December 2011 was performed. Variables analyzed included type of intervention performed, research methodology, and publication demographics such as surgical specialty, partnerships involved, authorship contribution, place and journal of publication. FINDINGS: A total of 2049 articles met the inclusion criteria between 2002 and 2011. The two most common study methodologies performed were case series (44%) and case reports (18%). A total of 43% of publications were without outcome measures. Only 21% of all publications were authored by a collaboration of authors from low-income countries and developed country nationals. The five most common countries represented were Nepal (429), United States (408), England (170), Bangladesh (158), and Kenya (134). Furthermore, of countries evaluated, Nepal and Bangladesh were the only two with a specific national journal. INTERPRETATION: Based on the results of this research, the following recommendations were made: (1) Describe, develop, and stimulate surgical research through national peer-reviewed journals, (2) Foster centers of excellence to promote robust research competencies, (3) Endorse partnerships across regions and institutions in the promotion of global surgery, and (4) Build on outcome-directed research.

The global birth prevalence of clubfoot: a systematic review and meta-analysis.

Background: Estimates of the birth prevalence of clubfoot in low and middle income settings range from 0.5 to 2 per 1000 births. However, there is currently no estimate of global birth prevalence of clubfoot. Methods: We conducted a systematic review of studies reporting the birth prevalence of clubfoot across all countries and regions worldwide in the last 10 years. Africa Wide Information, EMBASE, CINAHL, Global Health, LILACS and Medline databases were searched for relevant studies from January 1st 2012 to February 9th 2023. Pooled prevalence estimates were calculated using the inverse variance method, and a random effects model was applied to account for heterogeneity between studies. Quality appraisal was performed using a modified Newcastle-Ottawa Quality Assessment Scale for Cohort studies. This review was registered with PROSPERO, CRD42023398410. Findings: The search generated 757 studies. Thirty-five studies from 36 countries and five WHO regions were included. The pooled prevalence of clubfoot was 1.18 per 1000 births (95% CI: 1.00-1.36) based on data from 44,818,965 births. The highest prevalence rates were observed in low- and middle-income countries, particularly in the South-East Asia Region (1.80, 95% CI: 1.32-2.28) and the Africa Region (1.31, 95% CI: 0.86-1.77). We estimate that 176,476 (95% CI: 126,126-227,010) children will be born with clubfoot globally each year. Interpretation: This study provides a comprehensive estimate of the global prevalence of clubfoot and highlights the significant burden of this condition, particularly in low- and middle-income countries. The findings underscore the need for improving access to effective treatment and prevention strategies in resource-limited settings. Funding: SR received funds from the Global Clubfoot Initiative and the Rhodes Trust.

Time-dependent extracellular matrix alterations of young tendons in response to stress relaxation: a model for the Ponseti method.

The Ponseti method corrects a clubfoot by manipulation and casting which causes stress relaxation on the tendons. Here, we examined the effect of long-term stress relaxation on tendon extracellular matrix (ECM) by (1) an ex vivo stress relaxation test, (2) an in vitro tenocyte culture with stress relaxation and (3) an in vivo rabbit study. Time-dependent tendon lengthening and ECM alterations including crimp angle reduction and cleaved elastin were observed, which illustrated the mechanism of tissue lengthening behind the treatment-a material-based crimp angle reduction resulted from elastin cleavage. Additionally, in vitro and in vivo results observed restoration of these ECM alterations along with increased elastin level after 7 days of treatment, and the existence of neovascularization and inflammation, indicating the recovery and adaptation from the tendon in reaction to the treatment. Overall, this study provides the scientific background and information that helps explain the Ponseti method.

Using participatory action research to empower district hospital staff to deliver quality-assured essential surgery to rural populations in Malawi, Zambia, and Tanzania.

Background: In 2017 the SURG-Africa project set out to institute a surgical, obstetric, trauma and anesthesia (SOTA) care capacity-building intervention focused on non-specialist providers at district hospitals in Zambia, Malawi and Tanzania. The aim was to scale up quality-assured SOTA care for rural populations. This paper reports the process of developing the intervention and our experience of initial implementation, using a participatory approach. Methods: Participatory Action Research workshops were held in the 3 countries in July-October 2017 and in October 2018-July 2019, involving representatives of key local stakeholder groups: district hospital (DH) surgical teams and administrators, referral hospital SOTA specialists, professional associations and local authorities. Through semi-structured discussions, qualitative data were collected on participants' perceptions and experiences of barriers to the provision of SOTA care at district level, and on the training and supervision needs of district surgical teams. Data were compared for themes across countries and across surgical team cadres. Results: All groups reported a lack of in-service training to develop essential skills to manage common SOTA cases; use and care of equipment; essential anesthesia care including resuscitation skills; and infection prevention and control. Very few district surgical teams had access to supervision. SOTA providers at DHs reported a demand for more feedback on referrals. Participants prioritized training needs that could be addressed through regular in-service training and supervision visits from referral hospital specialists to DHs. These data were used by participants in an action-planning cycle to develop site-specific training plans for each research site. Conclusion: The inclusive, participatory approach to stakeholder involvement in SOTA system strengthening employed by this study supported the design of a locally relevant and contextualized intervention. This study provides lessons on how to rebalance power dynamics in Global Surgery, through giving a voice to district surgical teams.

Surgical capacity, productivity and efficiency at the district level in Sub-Saharan Africa: A three-country study.

INTRODUCTION: Efficient utilisation of surgical resources is essential when providing surgical care in low-resources settings. Countries are developing plans to scale up surgery, though insufficiently based on empirical evidence. This paper investigates the determinants of hospital efficiency in district hospitals in three African countries. METHODS: Three-month data, comprising surgical capacity indicators and volumes of major surgical procedures collected from 61 district-level hospitals in Malawi, Tanzania, and Zambia, were analysed. Data envelopment analysis was used to calculate average hospital efficiency scores (max. = 1) for each country. Quantile regression analysis was selected to estimate the relationship between surgical volume and production factors. Two-stage bootstrap regression analysis was used to estimate the determinants of hospital efficiency. RESULTS: Average hospital efficiency scores were 0.77 in Tanzania, 0.70 in Malawi and 0.41 in Zambia. Hospitals with high efficiency scores had significantly more surgical staff compared with low efficiency hospitals (DEA score<1). Hospitals that scored high on the most commonly utilised surgical capacity index were not the ones with high surgical volumes or high efficiency. The number of surgical team members, which was lowest in Zambia, was strongly, positively correlated with surgical productivity and efficiency. CONCLUSION: Hospital efficiency, combining capacity measures and surgical outputs, is a better indicator of surgical performance than capacity measures, which could be misleading if used alone for surgical planning. Investment in the surgical workforce, in particular, is critical to improving district hospital surgical productivity and efficiency.

Ending Neglected Surgical Diseases (NSDs): Definitions, Strategies, and Goals for the Next Decade.

While there has been overall progress in addressing the lack of access to surgical care worldwide, untreated surgical conditions in developing countries remain an underprioritized issue. Significant backlogs of advanced surgical disease called neglected surgical diseases (NSDs) result from massive disparities in access to quality surgical care. We aim to discuss a framework for a public health rights-based initiative designed to prevent and eliminate the backlog of NSDs in developing countries. We defined NSDs and set forth six criteria that focused on the applicability and practicality of implementing a program designed to eradicate the backlog of six target NSDs from the list of 44 Disease Control Priorities 3rd edition (DCP3) surgical interventions. The human rights-based approach (HRBA) was used to clarify NSDs role within global health. Literature reviews were conducted to ascertain the global disease burden, estimated global backlog, average cost per treatment, disability-adjusted life-years (DALYs) averted from the treatment, return on investment, and potential gain and economic impact of the NSDs identified. Six index NSDs were identified, including neglected cleft lips and palate, clubfoot, cataracts, hernias and hydroceles, injuries, and obstetric fistula. Global definitions were proposed as a starting point towards the prevention and elimination of the backlog of NSDs. Defining a subset of neglected surgical conditions that illustrates society's role and responsibility in addressing them provides a framework through the HRBA lens for its eventual eradication.