By Jordan A. Francke, MD, MPH, and Betelehem Asnake, MD, MS
“In a hospital in Shanghai today, where seventy-five women are in labor without anesthesia or analgesia, two to four mothers occupy a single bed and some sleep on the floor. Five premature infants occupy a single incubator. In Korea, Burma and China today, patients with perforated typhoid intestinal ulcers and peritonitis are being transported in wheelbarrows … to mission hospitals where surgery is demanded with neither intravenous fluids nor compressed oxygen… In equatorial South America today, in lands that gave us both curare and cocaine, abdominal sutures will break, wounds will dehisce because these drugs in sterile ampules we take for granted in Boston and New York were not available…”1 – Robert Hingson MD (1964)
Nearly sixty years ago, an American anesthesiologist by the name of Dr. Robert Hingson described healthcare disparities around the world. In his article, “An appraisal of control of pain on six continents during the current decade,” Hingson, who became the first Professor of Anesthesiology at the University of Tennessee and made significant contributions to the obstetric anesthesia in the refinement of continuous epidural anesthesia, enumerated the myriad ways in which unequal access to quality anesthesia and surgical care jeopardizes patients’ health and safety. Sixty years later, many of these disparities still exist.1
In 2010, there were over 400,000 operating theaters worldwide, with a rate of 6 operating tables per 100,000. However, they were not evenly distributed: all high-income subregions had more than 14 operating suites per 100,000 people, whereas all low-income subregions had fewer than 2 per 100,000. Stated another way, more than 2 billion people in the world live in subregions where fewer than two operating rooms exist per 100,000 people. Despite the concentration of surgically intervenable diseases being higher in low-income regions, the access to these resources is strikingly limited.2-3
Much of the focus of past global health interventions has centered around communicable diseases, such as HIV, tuberculosis, and malaria. However, thirty percent of the global burden of disease is treatable through surgery and anesthesia – the burden of trauma alone is more than HIV, tuberculosis, and malaria combined.4-5 In resource-limited settings, surgery and anesthesia rank near the level of vaccines in term of cost-effectiveness.5-6 Nevertheless, there remains a substantial dearth of these resources available.
Even within highly developed countries (i.e., the Global North), significant health disparities exist. Depending upon the neighborhood of the resident, a nearly 30-year discrepancy in life expectancy has been found across the city of Chicago.7-8 This trend is quite common across American cities – within California, a life expectancy of greater than 20 years has been described across various neighborhoods in Los Angeles and San Francisco.3,9 Both present and future American anesthesiologists have a charge to address this growing discrepancy in the increasingly complex healthcare system in which we practice.
Many current and prospective anesthesiology residents desire to pursue global health projects. A recent survey of resident physicians demonstrated 91% of 460 participants were interested in global health opportunities, and three-quarters stated that availability of global health outreach residency tracks would influence their ranking during the residency match.10-11 In a 2017 survey of 56 anesthesiology residency program directors, 61% directors said that their program offered a global health elective, and another ten directors whose programs lacked an elective wished they could offer one. The most commonly cited reasons for not offering the elective included (1) lack of funding, (2) lack of global health partner, and (3) lack of time within the parameters of training. Among the US anesthesia programs that do offer global health electives, many of them are short mission-trip style electives. Only a small handful of programs around the country have a formal pathway/track with associated curricula requiring readings and didactics to accompany the clinical care abroad.
The authors of this article represent the inaugural resident and director of the nation’s newest global anesthesia training pathway. Dr. Betelehem Asnake, attending anesthesiologist at the University of California, Los Angeles (UCLA) is our residency program’s new Director of Global Health Initiatives.
Dr. Asnake’s interest in global health stemmed from her native country Ethiopia where she grew up witnessing firsthand health disparities. Being raised in the midst of such a resource-poor country is what motivated her to initially apply to medical school. Like many of her classmates, she was excited to become involved in health equity work but also felt significant limitations on her time during medical school and residency training. After finishing her residency in anesthesiology, she was able to enter a fellowship training program at UCSF in Global Health Equity in Anesthesia (now under the UCSF Center of Health Equity in Surgery and Anesthesia). She describes this program as being pivotal and life- changing. It not only gave her dedicated time to spend and work on health equity topics (which would not have been possible to do during her residency training) but it also allowed her the freedom and flexibility to explore her own projects. While a fellow, she created the health equity curriculum for anesthesia residents which has been implemented within the UCSF anesthesia residency program and now within our UCLA program as well. She also started a pre-medical mentorship program for under-represented students by under-represented physicians called Mulu Mentor which has mentored over 40 students to date.
As the director of global health in anesthesia at UCLA, she founded a formal global health curriculum for residents while ensuring they also received hands-on clinical exposure in low-resource environments. She created a strong partnership with the largest hospital in Ethiopia, Black Lion, where residents and faculty will soon be able to rotate for clinical work and/or research. She also firmly believes that not all global health initiatives need to be in-person. Therefore much of the UCLA residents’ interaction with the anesthesia residents in low-income countries has been through a series of virtual lectures. These virtual lectures were launched earlier this year and they involve several members of the department who volunteered their time to oversee senior residents in their preparation and delivery of the lectures. There are currently 7 residents (one CA3 and six CA2s) within two training pathways, one focused on an elective clinical rotation and the other on a research/quality improvement project. The curriculum includes topics on the history of global health, introduction to global health in anesthesia, and pain and analgesia in the global context. Residents will also participate in a journal club where relevant anesthesia articles around health equity will be discussed. The creation of a core global health faculty has allowed for a speedy execution of the initiative this year and we plan on collaborating with our surgical colleagues in the future in collaborating on projects.
As the primary author of this article, I (Dr. Jordan Francke) have had the pleasure of serving as the first and only CA3 to participate in the program thus far. Throughout my CA3 year, I have attended monthly global health in anesthesia didactics led by UCLA faculty who have had firsthand experience navigating delivering anesthesia in resource-limited settings, and the safety challenges that can arise. As a physician deeply interested in the intersection of obstetric and global anesthesia (and pursuing a fellowship in obstetric anesthesia next year at Brigham & Women’s Hospital/Harvard Medical School), I have had the pleasure of designing and executing my own month-long Zoom-based remote lecture series for residents at the Black Lion Hospital in Addis Ababa, Ethiopia exploring the challenges and opportunities of providing quality maternal and neonatal care at the largest referral hospital in Ethiopia. It is our hope that the logistics of the program become even further developed, so that next year the six newly minted CA3 residents in the pathway will travel to Addis Ababa themselves in order to improve the pedagogical experiences through hands-on simulations and in-person didactics. Residents will also gain valuable experience of observing how surgery and anesthesia are done with fewer monitoring and pharmaceutical resources than they are accustomed to at a resource-rich, level 1 trauma center in a major US metropolitan area. It is also our hope to assist our partners at Black Lion Hospital to reciprocally travel to UCLA in the United States, and experience the differences in how we provide care to our patients and deliver didactics to the non-pathway residents in our program as well. It is our aspiration that this inaugural global health program will embolden these future attendings to pursue a career incorporating global anesthesia into their practice and shape the way they provide safe, quality anesthesia to patients of all backgrounds in their communities and around the world.
References
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