For over a decade, the Stanford Division of Global Health Equity (SGHE), within the university's Department of Anesthesiology, Perioperative and Pain Medicine, has worked with academic partners facilitating medical education and training for under-resourced settings. The WHO defined health in 1948 as: “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (asamonitor.pub/3qo5x4X). Physical health and mental health are both well recognized. Yet the barriers that prevent the social well-being of all people remain indistinct and unaddressed for some global health programs. Similarly undefined is the scope of work implied by the term “global.” Driven by safe anesthesia's promotion of physical health, many of SGHE's partners are anesthesia training programs located in low- and middle-income countries. However, with growing inequities in health care access and disparate health outcomes within the U.S., the Division calls for broadening the scope of global health to include the health of our local communities. By addressing social barriers faced by so many, global health is public health, and both start at home. Nowhere is this more apparent than with critical care capacity during the COVID-19 pandemic.
Rwanda's story of growth
Unlike the North American model, across most of the globe, anesthesiology is synonymous with critical care medicine. But very few providers in low- and middle- income countries (LMICs) are trained in critical care medicine. Few facilities possess the physical resources to provide ICU-level care (Lancet 2010;376:1339-46; JAMA 2016;315:753; PLoS One 2015;10:e0116949). This has proved a grave challenge historically, now amplified during the COVID-19 pandemic. SGHE's longest-running partnership in Rwanda serves as one example of the global neglect for critical care. With only one anesthesiologist in the country after the 1994 genocide, Rwanda did not have training for anesthesiologists until 2006 (J Anesth Hist 2017;3:5-11; Can J Anesth 2007;54:935-9). Initially staffed by volunteer teachers from Canada and the U.S., the residency program at the University of Rwanda steadily evolved (N Engl J Med 2013;369:2054-9). Now run by local leadership who are graduates of the program, anesthesia trainees learn from local faculty, an official Head of Department, and a residency Program Director. Since 2008, 32 physician anesthesiologists have graduated from the program, but brain drain takes one-third of graduates. None have been formally trained in critical care. In fact, Rwanda currently has only one physician fully trained in critical care medicine. With insufficient numbers of teaching faculty, specialized anesthesia training, including critical care, has yet to develop in the country.
Rwanda, a stunning example of growth, stability, and economic development over the last two decades, has a health care system still suffering constraints on basic resources. These challenges are greater for rural hospitals. Over the last 10 years, SGHE has worked with Rwandan leadership and other partners to increase capacity for ICU-level patient care. With a goal to create a formal ICU training program for physicians, these partners constructed a critical care curriculum that has subsequently been approved by University of Rwanda leadership. In February 2020, in-country preparations were under way for the first-ever national ICU symposium in Rwanda, with preparations cut short by the onset of the SARS-CoV2 pandemic. In-person education and exchange programs were abruptly placed on hold.
With the pandemic, there is an urgency to address critical care capacity. Oxygen delivery and time-critical patient care, whether inside or outside an ICU, are of the highest priority yet lacking in many places. In response, SGHE turned to remote learning by launching the Global Anesthesia and Critical Care Learning Resource Center (LRC) in May 2020. The LRC's online learning modules and interactive webinar sessions have proven useful in offering learners asynchronous, curated learning resources with synchronous discussions and mentorship. With content relevant to anesthesia, critical care, and the COVID-19 response, the LRC facilitates SGHE's academic partnerships, but also supports the learning of many others. Since its launch, the LRC has over 1,550 users from over 130 countries, capturing physicians, nurses, students, and biomedical technicians – all facing the physical, mental, and social challenges of the pandemic.
While focused on academic partnerships in low- and middle-income countries, the culmination of resource constraints, an emerging pandemic, and demands for critical care capacity soon brought SGHE closer to home. Within the borders of the country with the highest income globally, in July 2020, Stanford University received a request for assistance from Pine Ridge Hospital on the Oglala-Lakota Native American reservation in South Dakota. Fearing an inevitable surge of COVID-19 patients, tribal leadership worked with Indian Health Services, SGHE, and other partners to prepare the space, supplies, systems, and staff necessary to care for critically ill patients.
Health care gaps close to home
Within the U.S. there are 573 federally recognized American Indian and Alaska Native tribes. Each tribe has its own distinct culture, language, and tribal sovereignty (Ann N Y Acad Sci 2008;1136:126-36). Despite being within the borders of the wealthiest country, indigenous nations experience some of the worst health outcomes in the U.S. and globally. The life expectancy of Native Americans is 5.5 years less than all other races in the nation. Pine Ridge reservation has some of the highest rates of diabetes, obesity, and hypertension in the U.S. One in four children are born with fetal alcohol syndrome, and adolescent suicide rates exceed that of the U.S. population by 150%. Most blame multigenerational poverty, leading to poor health outcomes, on a long history of federal interference resulting in the reduction of tribal sovereignty, coupled with broken treaty agreements and misaligned governmental legislation. On the Pine Ridge Indian Reservation, the average life expectancy is less than that of Sudan, India, and Iraq (asamonitor.pub/3mEYsKV). Pine Ridge sits in the poorest county in the U.S. and has the lowest life expectancy in the western hemisphere except for Haiti (asamonitor.pub/3g6ZA7I). Global Health advocates need not travel far to support vulnerable populations and resource-poor sovereign nations.
With a small 45-bed hospital, Pine Ridge lacks an ICU and ICU-trained providers. Patients requiring higher-level care are transferred out by ambulance, helicopter, or fixed-wing flight, often to Rapid City over 90 miles away. Over July and August 2020, Pine Ridge Hospital leadership and Stanford teams worked together to complete a needs assessment, create potential ICU space, and educate local staff on the importance of vigilant monitoring, clinical recognition of patient deterioration, use of oxygen therapies, and the development of transport protocols for the critically ill. Yet, as of this writing, the numbers of COVID-19 patients in South Dakota have increased by 51% in the previous nine days. Pine Ridge Hospital had 17 COVID-19 patients on its inpatient ward with only 20 beds. Astutely, hospital leadership rapidly scaled up other wards as acute care areas, and the emergency department set up a modular care tent. According to one emergency medicine physician, over 90% of patients they test for SARS-CoV2 have positive results.
The surge in COVID-19 cases occurred despite wise public health policies enforced by tribal leadership on the reservation. Widespread testing and tracing, a public mask policy, and closing of roads leading to the reservation were unable to prevent the spread from surrounding areas that lack face mask mandates under South Dakota state jurisdiction. Now, when nearby hospitals become overwhelmed and winter weather conditions approach, Pine Ridge loses the ability to transfer its critically ill patients to higher levels of care. The socially disadvantaged Oglala-Lakota population, with higher risk factors for severe physical illness, suffer increased mental health and physical health consequences that further their disadvantage. Globally, while SGHE works in Pine Ridge beside teams from other academic institutions, to coordinate a volunteer response of ICU-trained physicians, nurses and respiratory therapists, Rwanda maintains some of the lowest COVID-19 numbers across the globe.
Health knows no borders
Health disparities and inequities in access are barriers regardless of location. One does not suffer from geographic location but from physical illness, mental illness, and insurmountable social disadvantage. All three make health less attainable. While some continue to define Global Health by work done through traveling to other countries, gross disparities are obvious within the borders of the U.S. and with vulnerable populations residing in any high-income country. Global health does not lead to health without addressing the physical, mental, and social barriers. With the long-term goal of expanding anesthesia and critical care capacity for under-resourced settings, these urgent gaps, even within our own borders, have come into focus through a pandemic's lens. Health and disease, similarly, know no borders.