Extending the WHO ‘Safe Surgery Saves Lives’ project through global oximetry

I read with interest the recent editorial by Merry et al. [1]; however, I feel that the rationale of the Global Oximetry Project discussed is questionable. It depends on the belief that the decline in anaesthetic mortality in developed countries is primarily due to pulse oximetry and that this can automatically be extrapolated globally if oximetry use is expanded worldwide. There is virtually no evidence to support this or the feasibility of implementing the project. If the significance of pulse oximetry in changing outcome is debatable in developed countries then there is every reason to question its benefit in poor countries [2]. Indeed, less sophisticated surgery, anaesthetic techniques that preserve oxygenation, infrequent use of opioids and a different patient population should tend to reduce the incidence of peri-operative hypoxaemia. Apart from the difficulties in procuring, maintaining and repairing oximeters, there is the crucial issue of the appropriate use of pulse oximetry by anaesthesia providers whose motives and circumstances differ vastly from their western counterparts. I believe the pilot project, described in the same Anaesthesia issue, has limited value since the countries chosen fall into the Medium Human Development group (according to 2009 rankings) and are not undisputedly poor [3, 4]. If anything, the pilot indicates that a larger educational package is required and that oximeters should not be provided in Middle Income countries, and raises doubts about the robustness of the pulse oximeters chosen and overall costs, which are all at odds with the notion of global provision of oximeters. Details of the Global Oximetry Project can be found online [5]. The strategy of the World Health Organization (WHO) seems strange. The main problems in the poorest countries are the quantity and quality of surgery but instead the WHO have focused on peri-operative mortality (which will not become a significant problem until surgery numbers increase), yet have not sufficiently analysed the problems or evaluated the potential solutions, of which pulse oximetry is only one. At the inaugural meeting of the project, local participants were grossly under-represented, with not one anaesthesia provider coming from an undisputedly poor country. The majority of participants were anaesthetists and WHO clinical advisers, but one might have expected experts from other fields such as anthropology and human development to contribute in this kind of undertaking. The significant representation of the medical technology industry suggests commercial gains are at stake and this does little to support local ownership or even the image of the WHO. Finally, there is no account of how the WHO will manage in countries where they have no access. The Global Oximetry Project is a vertical programme which, like all such programmes that target specific health issues, can have unintended detrimental effects on local economies and other aspects of health, often by diversion or depletion of resources. These issues have not been mentioned by the WHO. I believe this project is potentially cost-inefficient and western donors, the main WHO contributors, should expect to see their money spent wisely, backed by robust evidence. No external funding and no competing interests declared.Previously posted at the Anaesthesia Correspondence website: http://www.anaesthesiacorrespondence.com