One day for Africa: anaesthesia in Uganda and beyond

What facilities and equipment do you need to be able to safely provide the most basic anaesthesia for an adult patient who needs a laparotomy? Don't worry about awareness, smooth recovery, postoperative analgesia, nausea and vomiting and antibiotics: just concentrate on oxygenation, airway maintenance, depression of consciousness and prevention of aspiration. Now what do you need? The World Federation of Societies of Anaesthesiology (WFSA) tried to define the absolute minimum requirements for safe anaesthesia in 1992 [1] and these standards have now been brought up to date by Hodges et al. [2], who have also extended the question to cover emergency surgery for a child below the age of 5 years, provision of spinal anaesthesia, and operative delivery of a pregnant woman. The list is not long, is certainly not luxurious and is unapologetically ‘low-tech’. For the adult laparotomy, for example, all that is needed is a practitioner with access to a textbook and occasional updates, a supply of oxygen, a facemask, a tracheal tube, a laryngoscope with which to insert it and a brush with which to clean it, a pulse oximeter, suction, a table that tilts and the ability to measure haemoglobin concentration and blood glucose. It would be reasonable to ask for a reliable electricity supply (especially when using an oxygen concentrator), running water, gloves, bleach and disinfectant. As for drugs, we could just about get by with ketamine, thiopental, suxamethonium, a non-depolarising relaxant, a volatile agent (ether will be fine), an opioid, atropine, neostigmine and naloxone. Many UK anaesthetists have spent time in sub-Saharan Africa and other parts of the developing world and are only too aware that even this simple standard cannot always be achieved but, until now, we were largely reliant on anecdotal reports from one or two centres in a country. The relationship between these snapshots and the larger picture was far from clear, and extrapolation to other countries, in the face of the chaotic and often rapidly changing situation in much of the region, was little better than guesswork. The chances of the average African patient being able to access safe, basic anaesthesia were a matter of speculation. Hodges and her colleagues are therefore to be congratulated for seizing an opportunity to obtain a reliable impression of anaesthetic provision in one of the world's poorest countries. While teaching on an annual refresher course in Uganda – partially funded by the Association of Anaesthetists of Great Britain and Ireland (AAGBI) – they asked the participants to fill in a detailed questionnaire about the facilities available to them in their base hospitals. The 100% response rate means that they have managed to obtain accurate, on-the-spot data from 28% of Uganda's anaesthetic practitioners working in 48% of the country's hospitals and rural health centres. This is as close to a representative sample as is likely to come out of sub-Saharan Africa. Some of the findings are depressingly predictable, but others may even shock old ‘Africa hands’. There was only one medical anaesthetist amongst the 91 analysed respondents; this is the way of the poorest countries, whence doctors flee to the West to find a better life for their families, leaving the medical officers and nurses to run the service. Hodges chose to call these practitioners ‘anaesthetists’ for the purpose of her paper and, as they represent virtually the only providers of anaesthesia for a large swathe of the world's population, I will do the same. Although it was reassuring that so many were able to attend the update course where the study was carried out, fewer than half of these anaesthetists had access to a textbook. Only 23% of anaesthetists were able to tick all the boxes with respect to the quotidian requirements detailed above, meaning that 77% could not provide basic, safe adult anaesthesia. When the list was expanded to include equipment for paediatric anaesthesia, this figure rose to 87%, representing approximately 8000 children under the age of 5 in Uganda every year. Spinal techniques are widely and quite rightly regarded as the safest way to deliver lower limb, pelvic and even abdominal anaesthesia in the developing world, but over half of the respondents in this survey did not have regular access to the necessary local anaesthetic drugs, and others were deterred by lack of availability of spinal needles. One of the most depressing findings was that only 23% of anaesthetists could guarantee being able to find a brush to clean their tracheal tube between cases. The picture is even bleaker when it comes to Caesarean section, almost certainly the commonest emergency operation performed in Africa, during which a minimum of two lives are at risk. Nearly all respondents – 94%– reported that they did not have the facilities to do this safely. This represented a caseload in Uganda alone of nearly 33 000 mothers. Over three-quarters of anaesthetists did not have reliable access to magnesium sulphate and half of these could never obtain it. Magnesium is the extremely cheap and effective treatment for pre-eclampsia/eclampsia, a disease that was responsible for around 10–15% of the 247 000 maternal deaths in sub-Saharan Africa in 2000 [3]. Of all the health statistics monitored by the World Health Organization, maternal mortality shows by far the largest discrepancy between the developed and developing worlds [4]. The lifetime risk of dying from pregnancy-related causes for some African women may be as high as one in 13, which is 150 times greater than that in Europe [5]. This is particularly poignant as the loss of a mother is more than an individual tragedy; it often means that the other children who depend on her care are also severely – and sometimes fatally – disadvantaged. The figures revealed by this survey show that, despite the best efforts of all involved, 27 million Ugandans essentially enter a lottery every time they undergo anaesthesia – a lottery with poor odds of a happy outcome. What the authors cannot tell us is whether this problem is confined to Uganda alone. I have argued above that it would be foolish to try to extrapolate from one country to another, but it is unlikely that the Ugandan data differ wildly from most of sub-Saharan Africa. While per capita income is lower than average for the region, and the north of the country is scarred by the brutality of the Lord's Resistance Army, it has a comparatively stable government, and has largely recovered from the depredations inflicted by Idi Amin. It has a widely hailed AIDS prevention and treatment programme, and there has been evidence in the last few years of sustained economic growth [6]. If the situation in Uganda is bad, it is likely to be far worse in Ethiopia, Somalia, Tanzania and many other neighbouring countries. How should we, as anaesthetists and humanitarians, react to this situation? There are many calls upon our charity and generosity to support the developing world in general and Africa in particular, but I cannot help but think that we should owe a special duty to help our professional colleagues and their patients. So this editorial, which you are hopefully reading just after enjoying the excesses of the festive season, is meant to act as a call to arms. What can we do to help? Our colleagues in industry are doing their bit, in conjunction with innovators within the profession. Hodges and her colleagues report that only 26% of anaesthetists in their survey had regular access to a pulse oximeter, and this was identified as one of the most common suggestions from the respondents when they were asked what they needed to make their practice safer. The development of the clockwork radio by Trevor Bayliss [7] and the ‘One Laptop per Child’ project by Nicholas Negroponte of Massachusetts Institute of Technology [8] has shown that appropriate technology of this sort can be designed and – hopefully – distributed to where it is most needed. We would all agree that oximetry is a basic requirement for safe anaesthesia, especially where oxygen provision is haphazard, but the cost of pulse oximeters and the difficulty in maintaining them means that they are rarely available where they are needed most. A small international group of anaesthetists sponsored by the AAGBI and WFSA is now working with industry to develop a cheap, easily maintained oximeter (G. Thoms, personal communication). The programme is in its early stages, but deserves every encouragement and a lot more publicity. Surely this is the kind of project that could capture the public imagination and raise the profile of our specialty at the same time? The Editorial Board of Anaesthesia is doing its bit. In conjunction with a large number of our sister medical journals, and responding to a ‘global theme issue’ initiative from the Council of Science Editors [9], we are in the process of compiling a supplement to the journal which will address the state of our specialty in the developing world. This will be published by the end of the year, and will highlight deficiencies in provision of care, the challenges facing our colleagues around the globe, and projects like that described above which aim to focus technological expertise on developing appropriate solutions. The Association of Anaesthetists of Great Britain and Ireland is doing its bit. The International Relations Committee of the AAGBI has done sterling work for many years in providing financial support for educational programmes in the developing world, and supplying funding and lecturers for courses. Over 10 000 compact discs (CDs) of educational material have been sent to more than 50 countries. However, the AAGBI recognises that more needs to be done, and the Overseas Anaesthesia Fund (OAF) was started in 2005 to allow individual anaesthetists to donate directly to help their colleagues in the developing world. Small sums make a big difference: £15 will buy and pay the postage on a textbook, and £250 will equip a department with a library of books and CDs. The fact that OAF maintains close links with anaesthetists in the receiving hospitals means that, unlike many donations from well-meaning individuals, only appropriate and usable equipment will be sent to anaesthetic departments in Africa and elsewhere. Which brings me to how we as individuals can do our bit. Anaesthetists can support OAF by making regular monthly donations; £20 per month is the suggested sum, and one which most UK senior anaesthetists can probably spare without too much pain. I would like to make another suggestion, which perhaps carries more symbolic weight. When you return to your theatres, maternity units and critical care facilities in 2007, why not work one day for Africa? Divide your annual salary by 300 (allowing for weekends and so as not to strain the mental mathematic facilities too much) and contribute the resulting amount by visiting the AAGBI website and downloading the donation form [10]. And don't be modest about it; tell your colleagues, your surgeons – especially your surgeons – and even the local media about what you are doing and why. This journal has over 15 000 subscribers; to use a well-worn but succinct phrase ‘between us, we can make a difference’. As we enter 2007, anaesthetists in the UK, along with doctors from other hospital specialties, are facing an uncertain future. Our trainees are stressed by the ‘double whammy’ blows of a major overhaul in their route to accreditation and widespread vacancy freezes by Trusts desperate to balance their books. Our consultants are having to deal with an unprecedented level of public and supervisory scrutiny while resisting efforts to blame the sorry financial state of the National Health Service on the pay agreement imposed on them by the Department of Health. Hodges and her colleagues remind us that, despite our own privations, we are quite clearly still in a extremely privileged position when compared with our colleagues in sub-Saharan Africa and their patients. Occasionally stepping back, taking in the wider perspective and making an altruistic gesture might be good for us as well as for them.