Research at the District Hospital in Low-Income Countries

To the Editor As I have been following the peer-reviewed anesthesia literature in recent years, I am increasingly convinced that what is being published is relevant for less than one-third of the world’s population of physician and nonphysician anesthetists. I am an American board-certified anesthesiologist, and since 2014, I have been working as an anesthesiologist at a rural faith-based district hospital in Burundi, East Africa. Burundi is one of the poorest countries in the world with a poverty rate of 74.7% and has a human development index (HDI) score of 0.417, ranking 185 of 189 countries.1 Having worked for 10 years in the United States and now for 5 years in Burundi, I have seen first-hand the stark difference in anesthesia practices between high- and low-income countries. Given the paucity of research being performed in district hospitals in Sub-Saharan Africa, it was encouraging to read the recent article by Gajewski et al,2 entitled Anesthesia Capacity of District-Level Hospitals in Malawi, Tanzania and Zambia. This article highlights many of the factors that make research in these settings difficult including the fact that, of the 76 district-level hospitals surveyed, not 1 had employed a physician anesthesiologist. While the academic community continues to publish more and more complex research, the rural district hospitals in low-income countries are being left behind. A PubMed search using the keywords “district hospital Africa anesthesia” resulted in a total of 70 published articles. When the keyword “Africa” is replaced with “Burundi” that list falls to 3. While the research currently being published in high-income countries may be useful for those working in those settings, the vast majority of articles are neither translatable nor relevant for an anesthesia provider working in a low-income country. The obstacles to carrying out high-quality data collection and research in a district hospital in Sub-Saharan Africa are massive and include lack of man-power, funding, resources, and support and a poor understanding of research planning from statisticians. In addition to all this, patient consents often need to be translated into multiple languages for patients who are frequently illiterate. The Lancet Commission on Global Surgery published in 2015 brought to light the unfortunate truth that approximately two-thirds of the world’s population does not have access to safe and affordable surgical and anesthesia care when needed.3 Listed among their targets was for 100% of countries to begin tracking of postoperative mortality rates by the year 2030. It is my impression that we are far from being on track to achieve this goal. Data collection and research, in general, are exceedingly difficult for most of the world’s anesthesia providers. I implore the anesthesia research community to come together and consider how to support and engage in high-quality research in rural district hospitals in low- and middle-income countries. This will require time, funding, and expertise. However, without this engagement, these countries will continue to be left behind and anesthesia care for billions of patients will continue to suffer. Gregory C. Sund, MDDepartment of Anesthesia and ReanimationKibuye Hope Hospital/Hope Africa UniversityGitega, Burundi[email protected]