Correspondence
Global surgery initiative
in Greece: more than an
essential initiative
Conditions that are treated primarily
or frequently with surgery constitute
a substantial portion of the global
disease burden. At the same time,
development of safe, essential,
life-saving surgical and anaesthesia
care in low-income and middle-
income countries has stagnated
or regressed. 1 In 2012, injuries
caused nearly 5 million deaths
and 270 000 women died from
complications during pregnancy.
Many of these injury-related and
obstetric-related deaths, as well
as deaths cause by abdominal
emergencies, could be prevented by
improved access to surgical care.2
Health policy in resource-constrained
settings has focused on infectious
diseases; surgical capacity was often
viewed as a secondary priority. These
striking findings gave birth to the
idea of the WHO Global Initiative for
Emergency and Essential Surgical Care,
an initiative to meet the surgical needs
of people around the world. With
current rates of population growth
and migration flows, 6·2 billion people
will be living in countries below the
minimum recommended rate of
surgical care by 2035.1–3 The Lancet
Commission on Global Surgery reports
that 5 billion people do not have
access to safe and affordable surgical
and anaesthesia care.1,3
Greece is suffering a severe financial
crisis affecting all aspects of life.
Reductions in public expenditure
were the cornerstones of economic
adjustment programmes and the
Greek National Health System could
not be excluded from these measures
(health expenditure decreased from
10% to 6% of annual gross domestic
product).4 Unpublished experience
from acute care hospitals in Athens
suggests that the number and the
profile of the patients seeking medical
help during the years of the crisis have
www.thelancet.com Vol 388 September 3, 2016
shifted. The poorest socioeconomic
groups, including immigrants and
unemployed people, face difficulties
in accessing health-care services
and only seek help when diseases
have progressed. Moreover, Greece
can be considered the gateway to a
humanitarian disaster because of the
massive influx of transiting migrants.
The country is now working out
practical measures on how to host
40 000–60 000 refugees long term.
Nearly 60% of refugees and migrants
arriving in Greece are women
and children. This population has
specific health needs (pregnant and
breastfeeding women, unvaccinated
children, sexual violence, neonate
mortality, drug abuse, nutrition
disorders, alcoholism, injuries, and
exposure to violence).5
This explosive social mixture
makes the Global Surgery Initiative
a necessity in Greece. Despite the
fact that the Greek National Health
System treats people without medical
insurance, it is extremely difficult to
predict how the almost bankrupted
social security services will cover this
additional burden. Also, even though
essential surgical procedures rank
among the most cost-effective of
all health interventions, the current
Greek economy is highly unlikely to
be able to afford them. Thus, a clear
strategy is essential to strengthen
surgical capacity in a timely fashion
as part of integrated health-system
development. Coordination of skilled
human resources personnel, specialised
supplies, and infrastructure is also
required. Furthermore, essential surgery
should be financed early on the path to
universal health coverage.2 Finally, a
strategic plan of rearrangement of and
access to tertiary care hospitals requires
that such facilities be geographically
widely spread.
All the above needs meet the
principles of global surgery, which
could be a solution to the upcoming
challenges that the Greek National
Health System will face during the
financial crisis and refugee crisis. Thus,
an initiative for the introduction of
global surgery principles in Greece
should take place.
We declare no competing interests.
Dr Barry Slaven/Science Photo Library
*Demetrios Moris,
Evangelos Felekouras, Dimitrios Linos
dimmoris@yahoo.com
Department of Immunology, Lerner Research
Institute, Cleveland Clinic, Cleveland, OH 44195,
USA (DM); First Department of Surgery, National
and Kapodistrian University of Athens, Athens,
Greece (DM, EF, DL); and Massachusetts General
Hospital, Harvard Medical School, Boston, MA,
USA (DL)
1 Mock CN, Donkor P, Gawande A, et al.
Essential surgery: key messages from Disease
Control Priorities, 3rd edition. Lancet 2015;
385: 2209–19.
2 Weiser TG, Haynes AB, Molina G, et al. Size and
distribution of the global volume of surgery in
2012. Bull World Health Organ 2016;
94: 201–09.
3 Uribe-Leitz T, Esquivel MM, Molina G, et al.
Projections to achieve minimum surgical rate
threshold: an observational study. Lancet 2015;
385 (suppl 2): S14.
4 Moris D, Zavos G, Menoudakou G,
Karampinis A, Boletis J. Organ donation during
the financial crisis in Greece. Lancet 2016;
387: 1511–12.
5 Giannakopoulos G, Anagnostopoulos DC.
Child health, the refugees crisis, and economic
recession in Greece. Lancet 2016; 387: 1271.
Organ donation during
the financial crisis in
Greece
We read with great interest the
Correspondence in The Lancet by For the Lancet Commission on
Demetrios Moris and colleagues Global Surgery see http://www.
lancetglobalsurgery.org/
(April 9, p 1511–12)1 about the effect of
the financial crisis on organ donation
rates in Greece.
However, this remarkable decrease
in organ donor rates in Greece
was probably caused by the radical
changes in the corresponding legal
framework, which introduced the
presumed consent (opt-out) system
with the law 3984/2011.2 This law
established an initial version of a
system wherein failure to submit
a negative statement by a patient
could lead to the removal of the Submissions should be
made via our electronic
deceased organs without family submission system at
consent. Discussion of this law began http://ees.elsevier.com/
in 2010, and it was met by strong thelancet/
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