12/15/2017
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Imagine facing surgery without an anesthesiologist on hand


Friday August 11, 2017
By Susan Brink


An anesthesiologist at work. Caiaimage/Sam Edwards, Getty Images

In Africa as well as parts of Asia and Latin America, women and babies die when labor takes a complicated turn and there is no one to provide a cesarean section. Young people succumb to accidental injuries for lack of surgical interventions. A child born with a cleft palate or club foot suffers through a lifetime of disability because no team is available to provide routine surgery.

In a 2008 paper in the World Journal of Surgery, Dr. Paul Farmer wrote: "In Africa, surgery may be thought of as the neglected stepchild of global health." Farmer is a physician-anthropologist known for his humanitarian work with AIDS patients in Haiti.

Now the World Federation of Societies of Anaesthesiologists takes Farmer's insight a logical step further. "We describe anesthesiology as the invisible sister of the neglected stepchild of global health," says Julian Gore-Booth, chief executive officer of the WFSA.

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The lack of adequately trained anesthesia providers, plain and simple, means more people die in poor countries, according to Cliff Roberson, nurse anesthetist and anesthesia adviser at Doctors Without Borders. Fewer surgeries can be done, or are provided by people with poor or no training in anesthesia, he said in an email.

Blood pressure falls with anesthesia, something anesthesiologists are trained to deal with, but if it goes untreated, brain, kidney or other organ damage can occur.

The WFSA has released a map showing, country by country, the number of anesthesiologists worldwide. They found that wealthy countries, like the U.S. and Germany, have 20 to 30 anesthesiologists for every 100,000 people; but in sub-Saharan Africa and parts of Asia, there are often fewer than one for every 100,000 people. Here's a global sampling:

Switzerland: 54.22 per 100,000
Russian Federation: 20.91 per 100,000
United States: 20.82 per 100,00
South Africa: 16.18 per 100,000
Canada: 12.42 per 100,000
Cuba: 15.68 per 100,000
Mexico: 6.42 per 100,000
China: 5.12 per 100,000
Namibia: 4.7 per 100,000
Thailand: 2.45 per 100,000
Peru: 1.76 per 100,000
Gabon: 1.28 per 100,000
India: 1.26 per 100,000
Gambia: 0.1 per 100,000

And in some countries, the number of anesthesiologists is zero — like Somalia and the Central African Republic. These countries do have nurses with basic training to anesthetize patients — 32 in Somalia, for a population of about 15 million; 24 in CAR for a population of 5 million.

The WFSA recommends an interim goal of at least 5 providers per 100,000 people. NPR talked to Gore-Booth about the data on anesthesiologists.

Why is it important to compile these numbers and feature them in a map?

First, it's a workplace-planning tool so that countries can see how many anesthesiologists are available. But it's also an advocacy tool to bring attention to the shortage to trained providers. Five billion people around the world cannot access safe anesthesia and safe surgery. That's five out of seven people in the world.

As surgical capacity is slowly improving in the developing world, are there efforts to make safe anesthesia more widely available?

No. People who make resource decisions don't always understand the essential role of anesthesia in the provision of surgical care. The development of anesthesia has been given a lower priority than the development of surgery. But you cannot have surgery without anesthesia. The two are married. Access to safe anesthesia is often the limiting factor in providing surgery.

Who qualifies as an anesthesia provider?

An anesthesiologist is a physician who has gone on to do specialty studies, usually another three or four years, in anesthesiology. There are also nurse anesthetists, and qualifications vary from country to country. We believe strongly that anesthesiology should be physician-led, but we also recognize that this has to be a joint effort by physician and non-physician providers.

What is the reality in poor countries now without enough anesthesiologists?

The consequences are that in some parts of sub-Saharan Africa, people are 1,000 times more likely to die of complications related to anesthesia. It can be because of a lack of the essentials of safe anesthesia — adequate work force, proper equipment and appropriate medicines. But fundamentally, it comes down to a lack of trained providers. Anesthesiology is complex and hazardous. The anesthesiologist is in charge of care of the patient before, during and after surgery. If that person is not available, or not properly trained, then outcomes are far less positive.

What is being done to increase the capacity for surgical, and anesthesia, capacity in poor countries?

In 2015, the World Health Assembly passed a resolution to make surgical care and anesthesia a part of universal health care. Since then, we've been calling on the assembly to put together a plan that will turn the resolution into concrete action.

Is there a feeling that surgery is too expensive for the developing world?

That's a wrong perception. We can show now that the cost of essential surgery compares favorably with antiretroviral therapy (for AIDS) and with vaccinations, according to the 2015 World Bank Disease Control Priorities report. The World Bank has reported that for every dollar invested in anesthesia, you get $10 back in productivity.

And the basics of surgery — abdominal surgery like appendectomy, cesarean sections and setting large, broken bones — account for 80 percent of the need in poor countries. Those can be done cost effectively.

What countries are leading the way in increasing surgical and anesthesia capacity?

Zambia and Tanzania are putting together national surgical plans. They're setting money aside in their health budgets to transform surgery and anesthesia. And we're training anesthesiologists there. Ethiopia is working closely with donors to put together an obstetrics, surgery and anesthesia plan. They've done the health planning, and now they're beginning to implement the plans.

But the report makes it clear that many countries have a severe lack of anesthesiologists.

I find it bizarre that such a huge percentage of our world cannot access what most of us take for granted. It is as though surgery has become a luxury rather than a human right. That's why we're so active in this. There needs to be a much bigger noise around this.

Susan Brink is a freelance writer who covers health and medicine. She is the author of The Fourth Trimester, and co-author of A Change of Heart.



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