Photo courtesy of Saeedah Asaf, MD.

Photo courtesy of Saeedah Asaf, MD.

As I (MBR) entered the small OR, I saw a pregnant lady lying on the operating table. A surgical assistant was setting up the instruments, and an old anesthesia machine without a ventilator was at the head of the bed. The surgeon was scrubbed and ready, and I was supposed to provide general anesthesia for this “emergent” cesarean delivery. Monitoring was limited to my fingers on her carotid pulse. This was my first experience as a three-month anesthesia trainee, to go to a private clinic and provide anesthesia because a senior colleague was stuck in another case. I do not remember the details of the rest of the case, but I somehow accomplished the assigned task. On my way out of the OR, the surgeon handed me the service fee of Rs. 500.0 in cash (equivalent to $17 at the time). This took place in 1997 in Lahore, Pakistan. Soon after, I traveled to the United States and started my residency. Twenty years later, as part of a medical mission team in Pakistan, I (MBR) saw similar circumstances. The hospitals have antiquated anesthesia machines without any safety features intact, patient monitoring is usually a range of none to barely working pulse oximetry, minimal or no documentation of anesthesia care, and clinicians are working very long hours. Anesthesia personnel are usually paid by the surgeon at the end of the case. Although there are rules and regulations defining minimum standards for anesthesia care, the implementation is only a dream.

Low and middle-income countries (LMICs) are on every continent. They differ by governance, language, culture, and religion; all lack the resources to serve the public and provide for safe perioperative care. Each country has its own unique socioeconomic issues, and no Staff of Moses exists to solve them. Anesthesia care challenges in the LMIC include shortages of trained personnel, training opportunities, equipment, pharmacological agent availability, and monetary constraints, to name a few.

Professional societies that serve as guiding, advocacy, and support platforms for practicing anesthesiologists are either non-existent or lack the ability to perform their basic duties. Through personal communication, I am aware of one professional anesthesia society in an LMIC that does not even have a bank account to collect membership dues from its members. This provides a very small glimpse of the challenges faced by professionals in LMICs.

“Of all the forms of inequality, injustice in health is the most shocking and the most inhumane because it often results in physical death.” These words of Dr. Martin Luther King Jr. resonate deeply with me even today. While high-income countries are not spared from health care inequities, the disparities in access to are even more profound in LMICs. One may ask, “why should I as an average American care about what happens there when I have enough worries of my own?” The current coronavirus pandemic has shown too well that what happens across the world could very quickly happen across the street!

Nobel laureate Dr. Amartya Sen once said, “You need an educated, healthy workforce to sustain economic development.” Hence efforts to recognize cultural, ethnic, educational, and political factors affecting global health care disparities and their reparation assume paramount importance. In this month's ASA Monitor, Drs. Tuyishime, Powell, and Evans write of the disparity in physician anesthesia provider densities between high-income countries (HICs) and LMICs. They explore the differences in training circumstances, hardships, and barriers in getting adequate education and clinical experience. They also suggest possible actions that HICs can take to provide solutions. The authors detail the efforts of ASA and the World Federation of Societies of Anaesthesiologists in improving safety standards in surgical and obstetric anesthesia through multiple collaborations.

In “Partnerships: The Key to Our Future,” Drs. Drum and Workneh show us the many ways that global partnerships foster education, comradery, advocacy, training, quality and safety, and research. Partnerships are needed to help support young anesthesiologists around the world and encourage the growth and development of the specialty. They explore how the current pandemic has impacted the personal and professional lives of anesthesiologists and emphasize how strong communication skills are needed to be effective leaders at the institutional, local, and global levels.

The global health education-themed article by Drs. Missett and Kyne highlights how issues of global health have more recently focused on global health equity (GHE). They explain why a GHE-themed curriculum should be included in anesthesiology residency and how this may impact the future career path of trainees. They also explore what a GHE-focused curriculum and objectives might look like.

Speaking from vast experience on the ground, Drs. Asaf and Siddiqui explore “The Quality Chasm and Challenges in a Middle-Income Country Hospital,” with a close look at care in public versus private fee-for-service models. Dr. Asaf, a U.S.-trained pediatric anesthesiologist, dedicates 50% of her time and effort as anesthesiology chair of a public sector children's hospital. In her opinion, a well-organized and strong training program is key to improving care and promoting a culture of safety. The article also highlights the importance of charitable contributions in acquiring specialized equipment.

Sustained improvement in patient care requires cutting-edge research, which has unique financial and academic barriers in LMICs. In their feature article on Sub-Saharan African anesthesia and critical care research partnerships, Drs. Ulisubisya, Newton, Bould, and Lugazia explore how the COVID-19 pandemic has underscored the need for appreciating the relationship between regions of the world, even countries without shared borders, while considering individual national health care priorities. The article addresses gaps in research capacity and funding and delves into their root causes. They also stress that medical research, in the appropriate context, can generate and analyze data that can then help promote improved patient outcomes in other countries.

As long as health care disparities continue to exist, no country can fully thrive, and global economies will suffer because of them. As anesthesiologists, our knowledge and perspectives across different specialties of medicine are unique and put us at the forefront of perioperative medicine. The communication revolution through social media has increased awareness among the general public and, at the same time, has created opportunities for students and providers to learn from experts without leaving home. We have the power to influence change. We hope the following content in the ASA Monitor enlightens you on the enduring efforts to influence change and what we all can do to contribute.

Let the change begin!

Muhammad B. Rafique, MD, FASA, Associate Professor, Anesthesiology, Stritch School of Medicine, Loyola University, Chicago.

Muhammad B. Rafique, MD, FASA, Associate Professor, Anesthesiology, Stritch School of Medicine, Loyola University, Chicago.

Lalitha Sundararaman, MD, Clinical Instructor, Brigham and Women's Hospital, Harvard Medical School, Boston, and Madras Medical College, India.

Lalitha Sundararaman, MD, Clinical Instructor, Brigham and Women's Hospital, Harvard Medical School, Boston, and Madras Medical College, India.