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The World Bank will publish the nine volumes of Disease Control Priorities, 3rd edition, in 2015-16. Volume 1 - Essential Surgery-identifies 44 surgical procedures as essential on the basis that they address substantial needs, are cost eff ective, and are feasible to implement. This report summarises and critically assesses the volume's five key findings. First, provision of essential surgical procedures would avert about 1.5 million deaths a year, or 6-7% of all avertable deaths in low-income and middle-income countries. Second, essential surgical procedures rank among the most cost eff ective of all health interventions. The surgical platform of the first-level hospital delivers 28 of the 44 essential procedures, making investment in this platform also highly cost eff ective. Third, measures to expand access to surgery, such as task sharing, have been shown to be safe and effective while countries make long-term investments in building surgical and anaesthesia workforces. Because emergency procedures constitute 23 of the 28 procedures provided at first-level hospitals, expansion of access requires that such facilities be widely geographically diffused. Fourth, substantial disparities remain in the safety of surgical care, driven by high perioperative mortality rates including anaesthesia-related deaths in low-income and middle-income countries. Feasible measures, such as WHO's Surgical Safety Checklist, have led to improvements in safety and quality. Fifth, the large burden of surgical disorders, cost-eff ectiveness of essential surgery, and strong public demand for surgical services suggest that universal coverage of essential surgery should be financed early on the path to universal health coverage. We point to estimates that full coverage of the component of universal coverage of essential surgery applicable to first-level hospitals would require just over US$3 billion annually of additional spending and yield a benefit-cost ratio of more than 10:1. It would efficiently and equitably provide health benefits, financial protection, and contributions to stronger health systems.

Competing Interests: The authors report no conflicts of interest.

Background: The COVID-19 pandemic disrupted the delivery of surgical services. The purpose of this communication was to report the impact of the pandemic on surgical training and learner well-being and to document adaptations made by surgery departments., Study Design: A 37-item survey was distributed to educational leaders in general surgery and other surgical specialty training programs. It included both closed- and open-ended questions and the self-reported stages of GME during the COVID-19 pandemic, as defined by the ACGME. Statistical associations for items with stage were assessed using categorical analysis., Results: The response rate was 21% (472 of 2,196). US stage distribution (n = 447) was as follows: stage 1, 22%; stage 2, 48%; and stage 3, 30%. Impact on clinical education significantly increased by stage, with severe reductions in nonemergency operations (73% and 86% vs 98%) and emergency operations (8% and 16% vs 34%). Variable effects were reported on minimal expected case numbers across all stages. Reductions were reported in outpatient experience (83%), in-hospital experience (70%), and outside rotations (57%). Increases in ICU rotations were reported with advancing stage (7% and 13% vs 37%). Severity of impact on didactic education increased with stage (14% and 30% vs 46%). Virtual conferences were adopted by 97% across all stages. Severity of impact on learner well-being increased by stage-physical safety (6% and 9% vs 31%), physical health (0% and 7% vs 17%), and emotional health (11% and 24% vs 42%). Regardless of stage, most but not all made adaptations to support trainees' well-being., Conclusions: The pandemic adversely impacted surgical training and the well-being of learners across all surgical specialties proportional to increasing ACGME stage. There is a need to develop education disaster plans to support technical competency and learner well-being. Careful assessment for program advancement will also be necessary. The experience during this pandemic shows that virtual learning and telemedicine will have a considerable impact on the future of surgical education., (Copyright © 2020 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Impressive progress has been made in global surgery in the past 10 years, and now serious and evidence-based national strategies are being developed for scaling-up surgical services in sub-Saharan Africa. Key to achieving this goal requires developing a realistic country-based estimate of burden of surgical disease, developing an accurate estimate of existing need, developing methods, rigorously planning and implementing the plan, and scaling-up essential surgical services at the national level., (© 2018 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

The World Bank is publishing nine volumes of Disease Control Priorities, 3rd edition (DCP3) between 2015 and 2018. Volume 9, Improving Health and Reducing Poverty, summarises the main messages from all the volumes and contains cross-cutting analyses. This Review draws on all nine volumes to convey conclusions. The analysis in DCP3 is built around 21 essential packages that were developed in the nine volumes. Each essential package addresses the concerns of a major professional community (eg, child health or surgery) and contains a mix of intersectoral policies and health-sector interventions. 71 intersectoral prevention policies were identified in total, 29 of which are priorities for early introduction. Interventions within the health sector were grouped onto five platforms (population based, community level, health centre, first-level hospital, and referral hospital). DCP3 defines a model concept of essential universal health coverage (EUHC) with 218 interventions that provides a starting point for country-specific analysis of priorities. Assuming steady-state implementation by 2030, EUHC in lower-middle-income countries would reduce premature deaths by an estimated 4·2 million per year. Estimated total costs prove substantial: about 9·1% of (current) gross national income (GNI) in low-income countries and 5·2% of GNI in lower-middle-income countries. Financing provision of continuing intervention against chronic conditions accounts for about half of estimated incremental costs. For lower-middle-income countries, the mortality reduction from implementing the EUHC can only reach about half the mortality reduction in non-communicable diseases called for by the Sustainable Development Goals. Full achievement will require increased investment or sustained intersectoral action, and actions by finance ministries to tax smoking and polluting emissions and to reduce or eliminate (often large) subsidies on fossil fuels appear of central importance. DCP3 is intended to be a model starting point for analyses at the country level, but country-specific cost structures, epidemiological needs, and national priorities will generally lead to definitions of EUHC that differ from country to country and from the model in this Review. DCP3 is particularly relevant as achievement of EUHC relies increasingly on greater domestic finance, with global developmental assistance in health focusing more on global public goods. In addition to assessing effects on mortality, DCP3 looked at outcomes of EUHC not encompassed by the disability-adjusted life-year metric and related cost-effectiveness analyses. The other objectives included financial protection (potentially better provided upstream by keeping people out of the hospital rather than downstream by paying their hospital bills for them), stillbirths averted, palliative care, contraception, and child physical and intellectual growth. The first 1000 days after conception are highly important for child development, but the next 7000 days are likewise important and often neglected., (Copyright © 2018 Elsevier Ltd. All rights reserved.)

The Millennium Development Goals have ended and the Sustainable Development Goals have begun, marking a shift in the global health landscape. The frame of reference has changed from a focus on 8 development priorities to an expansive set of 17 interrelated goals intended to improve the well-being of all people. In this time of change, several groups, including the Lancet Commission on Global Surgery, have brought a critical problem to the fore: 5 billion people lack access to safe, affordable surgical and anaesthesia care when needed. The magnitude of this problem and the world's new focus on strengthening health systems mandate reimagined roles for and renewed commitments from high income country actors in global surgery. To discuss the way forward, on 6 May 2015, the Commission held its North American launch event in Boston, Massachusetts. Panels of experts outlined the current state of knowledge and agreed on the roles of surgical colleges and academic medical centres; trainees and training programmes; academia; global health funders; the biomedical devices industry, and news media and advocacy organisations in building sustainable, resilient surgical systems. This paper summarises these discussions and serves as a consensus statement providing practical advice to these groups. It traces a common policy agenda between major actors and provides a roadmap for maximising benefit to surgical patients worldwide. To close the access gap by 2030, individuals and organisations must work collectively, interprofessionally and globally. High income country actors must abandon colonial narratives and work alongside low and middle income country partners to build the surgical systems of the future., Competing Interests: Competing interests: AV is director of Developing Health Globally at the GE foundation, the philanthropic organisation of GE. SMR is Chief Executive Officer of Gradian Health Systems, a non-profit medical device company that manufactures and distributes technology for anaesthesia and surgical applications in low income environments.

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.

Background: The University of California-San Francisco's (UCSF) Master of Science (MS) degree in global health sciences, a 1-year degree program started in 2008, is the first accredited master's degree in global health in the country., Objective: The aim of this study was to review the genesis and structure of the MS degree program, and describe its progress over its first 5 years., Methods: We reviewed the program's teaching methods, academic curriculum, course evaluations, and backgrounds and outcomes of the first 127 graduates. Student opinions were gathered from anonymous course evaluations. Student outcome data and graduates' perspectives were gathered through a voluntary, anonymous, online survey. We reflect on student demand, program strengths and weaknesses, and future academic directions., Findings: The program's structure arose from three learning objectives identified by the Curriculum Committee: a multidisciplinary approach to the foundations of global health, an emphasis on research design and methods, and an application of theory to international fieldwork. The resulting broad curriculum has attracted students of diverse backgrounds, which has enriched classroom discussions. Over the first 5 years, the program revised its fieldwork project criteria to allow more flexibility in design, leading to a higher rate of publication and enabling students to graduate with an academic portfolio. Students have reported that the high faculty-to-student ratio has fostered strong mentorship relationships; this is vital as 66% of graduates work in academics. Graduates have reflected that group work in the program appropriately prepared them for their work environment. The program's experience has guided its response to: pressure to focus on medical aspects of global health; students' needs for career skill-building; financial challenges; and trends toward online didactics., Conclusions: The recent surge in interest in global health careers has created demand for academic programs. UCSF has designed the MS degree program to balance breadth and depth of learning in a multidisciplinary curriculum, and combine career preparation and theoretical learning in a one-year academic degree. The challenges of balancing breadth and depth of learning in a multidisciplinary program, and combining career preparation and theoretical learning in a one-year academic degree, have informed UCSF's MS program design., (Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.)

In 2005, Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania and the University of California San Francisco (UCSF) in the United States joined to form a partnership across all the schools in our institutions. Although our goal is to address the health workforce crisis in Tanzania, we have gained much as institutions. We review the work undertaken and point out how this education partnership differs from many research collaborations. Important characteristics include: (i) activities grew out of MUHAS's institutional needs, but also benefit UCSF; (ii) working across professions changed the discourse from 'medical education' to 'health professions education'; (iii) challenged by gaps in our respective health-care systems, both institutions chose a new focus, interprofessional team work; (iv) despite being so differently resourced, MUHAS and UCSF seek strategies to address growing class sizes; and (v) we involved a wider range of people - faculty, administrators, students, and residents - at both institutions than is usually the case with research. This partnership has convinced us to exhort other academic leaders in the health arena to seek opportunities together to enlighten and enliven our educational enterprises.

The creation of the University of California Global Health Institute represents a paradigm shift in structure and function. Its 3 centers of expertise (Migration and Health, One Health, and Women's Health and Empowerment) not only involve all 10 of the University of California campuses but also bring together a wide range of disciplines from both the health and nonhealth sciences. They have created truly interdisciplinary and transdisciplinary programs that are addressing complex global health challenges of the twenty-first century, training future global health leaders, and forging international academic partnerships., (Copyright © 2011. Published by Elsevier Inc.)

Background: There is a growing recognition that the provision of surgical services in low-income countries is inadequate to the need. While constrained health budgets and health worker shortages have been blamed for the low rates of surgery, there has been little empirical data on the providers of surgery and cost of surgical services in Africa. This study described the range of providers of surgical care and anesthesia and estimated the resources dedicated to surgery at district hospitals in three African countries., Methods and Findings: We conducted a retrospective cross-sectional survey of data from eight district hospitals in Mozambique, Tanzania, and Uganda. There were no specialist surgeons or anesthetists in any of the hospitals. Most of the health workers were nurses (77.5%), followed by mid-level providers (MLPs) not trained to provide surgical care (7.8%), and MLPs trained to perform surgical procedures (3.8%). There were one to six medical doctors per hospital (4.2% of clinical staff). Most major surgical procedures were performed by doctors (54.6%), however over one-third (35.9%) were done by MLPs. Anesthesia was mainly provided by nurses (39.4%). Most of the hospital expenditure was related to staffing. Of the total operating costs, only 7% to 14% was allocated to surgical care, the majority of which was for obstetric surgery. These costs represent a per capita expenditure on surgery ranging from US$0.05 to US$0.14 between the eight hospitals., Conclusion: African countries have adopted different policies to ensure the provision of surgical care in their respective district hospitals. Overall, the surgical output per capita was very low, reflecting low staffing ratios and limited expenditures for surgery. We found that most surgical and anesthesia services in the three countries in the study were provided by generalist doctors, MLPs, and nurses. Although more information is needed to estimate unmet need for surgery, increasing the funds allocated to surgery, and, in the absence of trained doctors and surgeons, formalizing the training of MLPs appears to be a pragmatic and cost-effective way to make basic surgical services available in underserved areas. Please see later in the article for the Editors' Summary.

Background: Surgical conditions contribute significantly to the disease burden in sub-Saharan Africa. Yet there is an apparent neglect of surgical care as a public health intervention to counter this burden. There is increasing enthusiasm to reverse this trend, by promoting essential surgical services at the district hospital, the first point of contact for critical conditions for rural populations. This study investigated the scope of surgery conducted at district hospitals in three sub-Saharan African countries., Methods and Findings: In a retrospective descriptive study, field data were collected from eight district hospitals in Uganda, Tanzania, and Mozambique using a standardized form and interviews with key informants. Overall, the scope of surgical procedures performed was narrow and included mainly essential and life-saving emergency procedures. Surgical output varied across hospitals from five to 45 major procedures/10,000 people. Obstetric operations were most common and included cesarean sections and uterine evacuations. Hernia repair and wound care accounted for 65% of general surgical procedures. The number of beds in the studied hospitals ranged from 0.2 to 1.0 per 1,000 population., Conclusion: The findings of this study clearly indicate low levels of surgical care provision at the district level for the hospitals studied. The extent to which this translates into unmet need remains unknown although the very low proportions of live births in the catchment areas of these eight hospitals that are born by cesarean section suggest that there is a substantial unmet need for surgical services. The district hospital in the current health system in sub-Saharan Africa lends itself to feasible integration of essential surgery into the spectrum of comprehensive primary care services. It is therefore critical that the surgical capacity of the district hospital is significantly expanded; this will result in sustainable preventable morbidity and mortality. Please see later in the article for the Editors' Summary.

The University of California, San Francisco (UCSF) established Global Health Sciences (GHS) as a campus-wide initiative in 2003. The mission of GHS is to facilitate UCSF's engagement in global health across its four schools by (1) creating a supportive environment that promotes UCSF's leadership role in global health, (2) providing education and training in global health, (3) convening and coordinating global health research activities, (4) establishing global health outreach programs locally in San Francisco and California, (5) partnering with academic centers, especially less-well-resourced institutions in low- and middle-income countries, and (6) developing and collaborating in international initiatives that address neglected global health issues.GHS education programs include a master of science (MS) program expected to start in September 2008, an introduction to global health for UCSF residents, and a year of training at UCSF for MS and PhD students from low- and middle-income countries that is "sandwiched" between years in their own education program and results in a UCSF Sandwich Certificate. GHS's work with partner institutions in California has a preliminary focus on migration and health, and its work with academic centers in low- and middle-income countries focuses primarily on academic partnerships to train human resources for health. Recognizing that the existing academic structure at UCSF may be inadequate to address the complexity of global health threats in the 21st century, GHS is working with the nine other campuses of the University of California to develop a university-wide transdisciplinary initiative in global health.

The shortage of qualified health professionals is a major obstacle to achieving better health outcomes in many parts of the world, particularly in Africa. The role of health science universities in addressing this shortage is to provide quality education and continuing professional development opportunities for the healthcare workforce. Academic institutions in Africa, however, are also short of faculty and especially under-resourced. We describe the initial phase of an institutional partnership between the Muhimbili University of Health and Allied Sciences (MUHAS) and the University of California San Francisco (UCSF) centred on promoting medical education at MUHAS. The challenges facing the development of the partnership include the need: (1) for new funding mechanisms to provide long-term support for institutional partnerships, and (2) for institutional change at UCSF and MUHAS to recognize and support faculty activities that are important to the partnership. The growing interest in global health worldwide offers opportunities to explore new academic partnerships. It is important that their development and implementation be documented and evaluated as well as for lessons to be shared.

In 1975, a trend began in which applications of MDs to the National Institutes of Health for research funding became less successful than applications from PhDs or MD/PhDs. MD/PhDs were the most successful applicants. Concomitantly, proposals for clinical research were less successful than nonclinical proposals. Since 1975, surgeons have fared disproportionately worse than researchers in other clinical disciplines in obtaining funding from the National Institutes of Health. Despite the efforts of surgical organizations, surgeons continue to fall farther behind in getting National Institutes of Health support for research. The most likely cause of this problem is that the surgical profession has failed to develop and sustain an adequate research workforce.

The Academy of Medical Educators at the University of California, San Francisco (UCSF), was established in 2000 to (1) foster excellence in teaching, (2) support teachers of medicine, and (3) promote curricular innovation. A membership organization, it recognizes five categories of educational activity: direct teaching, curriculum development and assessment of learner performance, advising and mentoring, educational administration and leadership, and educational research. Excellent medical student teaching and outstanding accomplishment in one or more areas of educational activity qualify a teacher for membership. Candidates prepare a portfolio that is reviewed internally and by national experts in medical education. Currently 37 faculty members, 3% of the entire school of medicine faculty, belong to the academy. The academy's innovations funding program disburses one-year grants to support curricular development and comparisons of pedagogical approaches; through this mechanism, the academy has funded 20 projects at a total cost of $442,300. Three fourths of expended funds support faculty release time. Faculty development efforts include promotion of the use of an educator's portfolio and the establishment of a mentoring program for junior faculty members built around observation of teaching. The Academy of Medical Educators vigorously supports expanded scholarship in education; the academy-sponsored Education Day is an opportunity for educators to present their work locally. Recipients of innovations-funding program grants are expected to present their work in an appropriate national forum and are assisted in doing this through quarterly scholarship clinics. The Academy of Medical Educators has been well received at UCSF and is enhancing the status of medical education and teachers.

The sulfated and unsulfated forms of cholecystokinin-octapeptide (CCK-8) were compared, with respect to their effect on gastric acid secretion, in the rat. Unsulfated CCK-8 stimulated acid secretion in a dose-dependent manner, while the sulfated form was without stimulatory effect; thus, sulfation of the tyrosine residue in the seventh position from the C terminus completely abolished the gastrin-like action of CCK-8. Compared with pentagastrin and human gastrin II, unsulfated CCK-8 gave lower calculated maximal response. While sulfated CCK-8 given alone had no effect on acid secretion, it caused marked inhibition of the plateau response to submaximal pentagastrin. This inhibition was surmountable with higher doses of pentagastrin, suggesting a competitive type of inhibition. It is, therefore, concluded that lack of sulfation of the tyrosine residue in the seventh position does not exclude CCK-8 from occupying the gastrin receptor; but does prevent the hormone-receptor interaction that leads to the secretory response. These observations in the rat are different from those in the dog where desulfation of tyrosine renders the CCK analog, caerulein, ineffective in its ability to stimulate acid secretion., (Copyright 2000 Academic Press.)

We investigated the effects of the sensory neuropeptide substance P (SP) on amylase and fluid secretion in the isolated vascularly perfused rat pancreas. SP inhibited CCK-induced amylase release and secretin-induced juice flow via the pancreatic duct in a dose-related fashion. Threshold inhibition occurred following addition of 10(-10) M SP to the perfusate, and maximal inhibition was seen with 10(-8) M SP. The effects of SP were partially blocked by both the neurokinin-1 (NK1) and neurokinin-2 (NK2) receptor antagonists. Atropine and TTX blocked SP-induced effects on both amylase secretion (26 and 63% blockade, respectively) and pancreatic juice flow (21 and 79% blockade, respectively). Excitation of pancreatic sensory nerves using capsaicin (in the absence of SP) inhibited both amylase and pancreatic juice flow via activation of the NK1 receptor. We conclude that SP inhibits exocrine secretion via an indirect neural mechanism.

There is general agreement that the exocrine pancreas derives from the endoderm of the embryonic foregut. The cellular origin of the endocrine pancreas has been debated for a long time. A hypothesis existed that the endocrine cells of the pancreas originated from the neural crest of the embryo. The recent application of microdissection of the mouse embryo and an exquisitely sensitive polymerase chain reaction assay (PCR) indicates that both the exocrine and endocrine cells of the pancreas develop from the endoderm of the foregut as evidenced by the expression of genes responsible for acinar enzymes and islet hormones in the foregut at the site where the future pancreatic diverticulum would form. Furthermore, the mesenchyme surrounding the primitive endoderm cells from which the pancreas would form exerts significant regulation of differentiation of the pancreas. In culture or in vivo explants, these endoderm cells differentiate only into islet cells in the absence of mesenchyme. On the other hand, when these cells are cultured in vitro with mesenchyme, they differentiate to form not only islets but also ducts and acini.

The vagus is a mixed nerve containing cholinerrgic and non-cholinergic neurons. Vagal fibers interact with peptidergic neurons of the enteric nervous system which stain immunohistochemically for cholecystokinin, vasoactive intestinal polypeptide, and gastrin releasing peptide. The contribution of these peptidergic neurons in the pancreatic response to vagal stimulation is unknown. We tested the effect of specific inhibitor of these stimulants against vagally mediated exocrine secretion in rats. The response to vagal stimulation was blocked significantly by each of the following: the ganglionic blocker hexamethonium (100% inhibition); the muscarinic, cholinergic blocker atropine (85% inhibition); the specific cholecystokinin-A receptor blocker (91% inhibition); and a vasoactive intestinal polypeptide polyclonal antibody (89% inhibition). This observation is consistent with the hypothesis that potentiating interactions among several agonists mediate the vagal response. Our study, however, dose not exclude acetylcholine as the final common mediator.

Although cholecystokinin is localized within neuronal fibres of the pancreas, a physiological role for intrapancreatic cholecystokinin has not been identified. The strategy of this study was to elicit pure vagal stimulation electrically, and to use specific receptor antagonists to identify the mediators of exocrine pancreatic secretion. We conclude that vagal stimulation of the rat pancreas involves ganglionic neurotransmission and release of acetylcholine and cholecystokinin from intrapancreatic, postganglionic fibres. To our knowledge, this is the first study to demonstrate a physiological role for intrapancreatic cholecystokinin.