Realities of Anesthesia Care in Resource-limited Settings.

Anesthesiology, V 124 • No 3 521 March 2016 T HE important work of Doctors Without Borders (Médecins Sans Frontières [MSF]) in providing safe anesthesia and, in many low-income countries, providing education and training for local providers, cannot be overstated. “Providing anesthesia care in resource-limited settings: a six year analysis of anesthesia services provided at Médecins Sans Frontières facilities” provides valuable insight into the realities of anesthesia care in many low-income settings, including higher than expected perioperative mortality rates especially with general anesthesia with intubation.1 Countries designated as low income by the World Bank have had little or no access to surgical care for more than 25 yr. This unfortunate reality was the result of the burgeoning acquired immunodeficiency syndrome/human immunodeficiency virus epidemic and the fact that contagious disease demanded a majority of the healthcare resources in resource-constrained economies. This resulted in few physicians being trained in anesthesia (in many places, there is not even one anesthesiologist per 1 million people), many anesthesia providers delivering suboptimal care, and a shocking lack of resources such as essential medicines including oxygen, pulse oximeters, and other resuscitation equipment. It should not surprise the readership that the lack of essentials and little focus on patient safety resulted in high perioperative mortality rates, prominently in otherwise healthy patients, including expectant mothers and children. Only now, in an era of global surgery, with a committed focus on surgery and safe anesthesia by the World Health Organization, World Bank, and others, there is an international commitment to improving anesthesia and surgery as part of Universal Health Coverage 2016 to 2030.2 Organizations such as MSF have been leading such efforts long before this era began, and this 6-yr report is an important primer for all those interested in service, training, and education in lowand middle-income countries (LMICs). In the best interest of the many patients awaiting basic surgical care and safe anesthesia, much more needs to be done, as soon as possible. It is estimated that at least 25% of the global burden of surgical disease could be averted, treated, or improved through the provision of emergency and essential surgical care.3 Further, and even more shocking, are the estimates that 5 billion people worldwide, two third of the global population, lack access to surgical care.4 Thanks to the efforts in 2015 from the World Bank, and the Lancet Commission on Global Surgery efforts are underway to address this crisis. Anesthesiology is one focus of these efforts, because anesthesia is central to perioperative and surgical care and is the rate-limiting step to access and patient safety in LMICs. Goals set by the World Bank and Lancet include providing basic surgery and safe anesthesia at community hospitals, where patients can access care within 2 h by foot; increasing the number of surgical, anesthesia, and obstetric providers; and tracking perioperative mortality rates to benchmark improvement and provide quality measures. This may sound obvious and minimal to readers in high-income counties, but these basic and critical steps are what are needed now in countries where resources limit access to emergency C-sections, appendectomy, hernia repair, and 41 other cost-effective procedures. Many in global health discounted the surgical agenda for decades, claiming that surgery was too expensive and Realities of Anesthesia Care in Resource-limited Settings