International Anaesthesia Challenges
Dr Iain Wilson, Exeter, President of AAGBI
The meeting was opened by Dr Bill Taylor, the immediate past President of the LMI who welcomed the audience and handed over to Dr Christine Bell, the President of the LSA. Before the main speaker, Dr Raymond Ahearn spoke briefly about his recent trip to Hungary at the invitation of the University Department of Anaesthesia in Pecs. Dr Ahearn spoke about the historical links between Liverpool and Pecs and was disappointed that due to changes in recruitment, this training relationship was no longer possible.
Dr Bell introduced the main speaker, Dr Iain Wilson, the President of the AAGBI. Dr Wilson started his talk by looking at the health service that we all take for granted with easy access to general practice, accident and emergency with its high standard of care which is all paid for within the taxation system. He then looked at UK public spending on healthcare which had more than doubled in the last ten years. He contrasted this with healthcare in the third world, where there is very limited access to surgery and anaesthesia because facilities, equipment and drugs are in very short supply with a variable standard of care.
Dr Wilson talked about his interest in anaesthesia in the third world which had started when he was a lecturer in Zambia between 1986 and 1988. He then looked at the distribution of doctors throughout the world per head of population. The developed world had on average more than 100 doctors per 100,000 population, whereas in some parts of sub-Saharan Africa, this figure was as low as 5 doctors per 100,000. This was partly due to very low training numbers; for example in Ethiopia with a population of 75 million, only 200 doctors are trained per year, which he compared with the UK where the annual training number is 6000. In Uganda, with a population of approximately half of the UK, there are only 13 medical anaesthetists, compared with 12,000 in the UK. With the small numbers of doctors trained in third world countries, migration is also a problem.
Dr Wilson then looked at access to surgery and anaesthesia. In a survey of 72 Ugandan hospitals serving a population of 6 million people, only 29 performed surgery, of which no hospital met WHO standards. The rate of surgery in children under 15 years was 3% of that in the UK. This was due to inadequate facilities, equipment and drugs, primarily caused by a lack of money. Dr Wilson highlighted this by looking at the economic state of Uganda where the expenditure on healthcare was $20 per year per capita. This contrasted with the UK figure of $2,850 per year. Other stark statistics were shown, such as the maternal mortality being 70 times greater in Uganda than the UK. Dr Wilson highlighted the difficulties obtaining basic drugs such as oxytocin, ergometrine and even oxygen which went some way to explain the greatly increased maternal mortality.
Dr Wilson spoke about the type of equipment that was required in the third world and contrasted the modern anaesthetic machines with the type of machines being developed for the third world. These were relatively simple with oxygen concentrators and draw over vaporisers. He then looked at outcomes from anaesthesia; in 1985, anaesthesia mortality in the UK was 1:187,000. In 2000 both in Malawi and Zimbabwe, anaesthesia mortality was 1:500. The majority of these deaths were related to respiratory causes such as aspiration, oesophageal intubation, postoperative hypoxia and overdose. A study from Australia had highlighted the importance of pulse oximetry for detecting critical incidents during anaesthesia. Dr Wilson highlighted the rapid uptake of pulse oximetry since 1985 when it was first introduced, which had further reduced mortality even in the UK. He asked why there were so few pulse oximeters in the third world. The principal reason was expense, particularly when probes are fragile and have to be regularly renewed. With a limited healthcare budget there were often other spending priorities, in particular HIV.
Dr Wilson spoke about the work of the AAGBI which had an international relations committee and a fund for overseas anaesthesia. In Africa in particular, anaesthesia was an unpopular speciality because of the type of work, the poor image of the specialty and the very low earning potential. The AAGBI had recently introduced a fellowship scheme to encourage more young doctors into anaesthesia, and this had been successful in recruiting fellows into anaesthesia. The AAGBI had also been successful in organising educational material such as books and online tutorials.
Dr Wilson discussed the global oximetry project. This had initially looked at quantifying the occurrence of oximeters in operating rooms which in Uganda was a figure of 63%. When oximeters were then introduced, practice had been shown to have significantly changed. It confirmed what was already known, that oximetry was an essential safety item and highlighted the importance of bringing this equipment to all operating rooms and beyond. The work of the WHO was then discussed and an essential step in the surgical safety checklist had been introduced which asked if a pulse oximeter was attached to the patient and functioning, The WHO also introduced specifications for oximetry and a tendering process had been performed by the World Federation of Societies of Anaesthesia. The outcome of this project has been to produce an oximeter which would normally cost $750 for $250 with a probe costing $25. 80,000 oximeters would be required just for operating theatres. This figure would greatly increase with use in recovery and on the wards. Branding of the oximeter was important and for this reason the word “Lifebox” had been adopted for this piece of equipment. A website is in development and soon these items will be able to be ordered online at the same price throughout the world. Dr Wilson emphasised the importance of education in ensuring that oximeters are used correctly, and an educational CD-ROM in six languages came with the “Lifebox”. Publicity for this initiative was currently being addressed but it had been recently helped by an article in The Lancet reporting this initiative.
Dr Wilson said that the “Lifebox” project was not just about oximeters but also a way to build global partnerships for international surgery and anaesthesia provision with greater safety. This will be a first step in improving procurement by combining markets so that basic equipment would be available at much lower prices.
Dr Wilson finished his talk and took many questions from the floor. Dr Edwin Djabatey gave the vote of thanks and the meeting finished at 20.15.
17th January 2011