This study reveals global variation in end colostomy rates after left-sided colorectal resection; stoma rates in low-HDI countries were twice those in middle- and three times those in high-HDI countries. Awakening after surgery with a colostomy will have been a traumatic experience for all 362 patients. I wish we could ask everyone who still survives today some honest questions about their quality of life since. I imagine those in high-HDI countries will have adapted better to their changed bodies and altered selves than their low-HDI counterparts. In high-HDI England my own stoma is easy to accommodate thanks to freely accessible healthcare, uninterrupted supplies of decent ileostomy bags, sanitation, plentiful water, an angel of a specialist stoma nurse, and legal protection from societal or workplace discrimination: I am fortunate to enjoy a lovely life as a ‘Bag Lady’. The absence of such enabling factors can, however, make having a stoma far more burdensome in low-HDI countries. Financial ruin, inability to resume usual daily activities, societal rejection, family/community shame, and becoming unemployable and unmarriageable are, sadly, common sequelae. Indeed, my East African-born parents insist that had I not been ‘Made in Britain’ long after they relocated to England, I would have suffered ‘intolerable strife or loss of life’. There is a real need to reduce avoidable stoma formation globally. This need is most pressing in low-HDI countries where physical, psychological, economic, educational and social challenges are magnified. The insurmountable obstacles they may face in low-HDI settings can lead patients to question whether surviving surgery is in fact the superior of the two possible outcomes. Thus, although surgeons in restricted-resource settings may have good reason to fear the consequences of anastomotic leaks, patients may have greater reason to fear the lifelong consequences of a stoma