The best surgery

The one that never happens

Dr Almas Khattak and Dr Tariq Khan Hashim

As surgeons, we are trained to act decisively in moments of crisis. We step in when something has already gone terribly wrong —when fragile newborns need complex surgery within hours of birth, when families are terrified, and when a child’s future is suddenly in our hands. 

But some of the hardest cases we see are the ones that never should have reached us at all. 

At hospitals across Pakistan, we regularly care for infants with neural tube defects– serious malformations of the brain and spine that develop in the earliest weeks of pregnancy, often before a woman even knows she is expecting. Spina bifida, one of the most common forms, can cause permanent paralysis and profound development challenges. Babies born with spina bifida require immediate and invasive surgery. Even when the procedure is successful, the road ahead is rarely easy: prolonged recoveries, repeat operations, risk of infection, and long-term disability. 

We see the toll these conditions take not just on a child’s health, but on families’ lives. Parents miss work to care for their children. Medical costs pile up. In communities already stretched thin, a preventable condition can reshape a family’s future. 

Pakistan bears an extraordinary burden of neural tube defects. Regional studies estimate rates to be more than six times the global average. Yet even these numbers likely underestimate the true scale of the challenge. Behind every statistic is a child undergoing surgery, and a family facing unimaginable choices.

What makes this crisis especially painful is that we know how to prevent most of these cases.

Decades of research have confirmed a strong link between neural tube defects and folate deficiency in a women’s diet before and during early pregnancy. Yet healthy diets remain out of reach for 80 percent of our population. Beyond this, about half of women of reproductive age in Pakistan are folate-deficient, increasing the risk of babies born with neural tube defects.  

That is where food fortification comes in.

Food fortification —adding essential vitamins and minerals to everyday staples like wheat flour, rice, oil, and salt —is one of the most effective public health interventions available, working to prevent billions of nutrient deficiencies each year. It works quietly, consistently, and at scale to reach families regardless of income, education, or geography. Compared with the lifelong cost of treating neural tube defects —surgery, rehabilitation, mobility support, and lost productivity —the return on investment is extraordinary.

Pakistan has made incredible strides to implement and scale food fortification. Almost 100 percent of edible oil in the country is fortified, and iodized salt is expanding with improved inspection and quality assurance systems. 

Wheat flour is the most recent addition to Pakistan’s food fortification efforts. While several provinces have introduced mandatory standards, achieving meaningful and sustained public health impact will require the adoption and enforcement of national legislation to ensure uniform coverage across the country. A nationwide mandatory wheat flour fortification programme could deliver significant health gains, including reductions in neural tube defects and other conditions, like anemia, that are related to a lack of essential nutrients.

Pakistan cannot afford to rely on incremental progress. Accelerating impact will require the establishment of mandatory national standards for wheat flour fortification, alongside continued strengthening and enforcement of existing salt and edible oil fortification programmes. Together, these measures would help build a more consistent and effective national approach to addressing widespread nutritional gaps.

As physicians, we believe deeply in the power of prevention because it is more powerful than any procedure we could perform. Our responsibility does not end when we leave the operating room. It extends to speaking up when we see suffering that can—and should—be prevented. 

That is why we recently attended the World Health Assembly in Geneva—not to showcase surgical techniques, but as physicians engaging directly with Ministries of Health to advocate for preventive action that improves nutrition, reduces the burden of disease, and helps ensure that fewer babies ever require surgical care. Pakistan has already demonstrated leadership through the fortification of salt and edible oil; the next critical step is to build on this foundation by implementing national wheat flour fortification as a strategy to prevent neural tube defects and other avoidable conditions.

Every delay has a human cost—more children undergoing preventable surgery and more families carrying avoidable burdens. This is a crisis we can stop.

Dr. Almas Khattak is a public health, global surgery, and health systems professional currently serving as Research Director at Medical Teaching Institution, Hayatabad Medical Complex Peshawar..

Dr. Tariq Khan Hashim is Professor and Head of the Department of Neurosurgery at Northwest School of Medicine, Peshawar, Pakistan.