Synapse: Current Issue

Performing surgery in an operating room without a highly skilled and qualified anesthesiologist in the United States is a malpractice lawsuit waiting to happen. In many of the developing nations of Africa however, it is the norm. In fact, having an anesthesiologist present is somewhat of an anomaly in and of itself. The relative lack of anesthesiologists in many of these countries causes multi-fold increases in mortality rates and complications associated with surgery.

This dearth of anesthesiologists was among the major topics discussed by the World Federation of Societies of Anesthesiologists (WFSA) at the 14th annual World Congress of Anesthesiologists held in Cape Town, South Africa in March 2008. In many developed countries, the ratio of anesthesiologists to citizens is on the order of one to a few thousand. The United Kingdom, for instance, has approximately one registered anesthesiologist for every 2500 people. For the developing nations of Africa, however, the ratio turns particularly bleak. Malawi, for instance, has four specialists for its population of 12.5 million people. Zambia has one registered specialist for every 3 million citizens.

Given the general scarcity of physicians in Africa; however, one must question whether in the grand order of operations, the issue of anesthesiology needs be addressed before the lack of general practitioners or general surgeons. Put another way, just how important is anesthesiology in terms of patient outcome and care? According to Peter Kempthorne, chairman of WFSA’s taskforce assigned to this issue, the worldwide mortality rate attributable to anesthesia-related complications is one in 300,000 surgical procedures. In Malawi, he says that chance of dying during an operation is one in 500. With such a drastic disparity, it becomes evident that it is a very important aspect of an operation. So what can be done? Is training more anesthesiologists the simple cure needed to ameliorate these rates?

According to Dr. Alexander Ayzengart, a resident in general surgery at UCSF who recently spent a month in Uganda as part of a surgical team, the problem is more systemic than merely a question of training more physicians. Dr. Ayzengart cites that in addition to the lack of infrastructure to train specialists, the “brain-drain” is a valid multifactorial phenomenon in the developing world that hampers efforts to increase the number of physicians. In describing the problem, Dr. Ayzengart noted that “in order to get the appropriate residency or subspecialty training, most doctors have to leave Uganda and go elsewhere (usually South Africa, China, India or Europe) and then, you have the whole economical stimulus factor where compensation in Europe and the U.S. is much better than anywhere in the developing world.” Coupled to this problem, he also notes “all western countries are currently experiencing physician shortage, so they are actively recruiting physicians from abroad.”

Given the issues regarding the flight of African-born physicians, the lack of healthcare infrastructure, and the economic challenges of supporting highly trained medical teams, sustainable solutions have been infrequent. The highly touted and often publicized journey of the Western physician into the squalor of the developing world to emphatically render healthcare accessible to all has become more clichéd medical-tourism than medical solution. In the eyes of Dr. Errol Lobo, Assistant Professor of Anesthesiology at UCSF, this naïve notion represents the age-old truism, “feed a man today; he’ll be hungry tomorrow.” In his opinion, solutions to the shortage of anesthesiologists does not involve sending doctors to Africa for two weeks to perform a dozen surgeries; nor does it necessarily involve increasing the number of doctors trained in perioperative care. Instead, Dr. Lobo feels that focusing on extensive training programs geared at technicians and nurses could pose a viable solution. In speaking about ways in which UCSF could get involved Dr. Lobo says, “UCSF could play a role in education and allowances for faculty and senior residents to play an integral role in development. UCSF could provide leadership to set up centers to train people, not necessarily physicians but highly skilled technicians.”

Dr. Gerald Dubowitz, an Assistant Professor of Anesthesiology at UCSF, has spent many years tackling this issue and devising means of providing sustainable solutions. Dr. Dubowitz believes the number of anesthesiologists can successfully increase throughout Africa if the specialty has more status within the medical fields of these countries. In his opinion, “Nobody wants to do anesthesiology because everybody thinks it’s a horrible profession that kills people.” Changing that mindset will require “improving the environment—not just going to paint the walls—but creating academic collaborations with universities in the United States that will give them credibility and strength.” Together with other doctors from UCSF, Dr. Dubowitz has worked to develop a collaborative organization called Global Partners in Anesthesia and Surgery that focuses on training highly skilled physicians in African countries through collaborations with professors and researchers in U.S. institutions. The idea is that these academic partnerships can make the specialty more attractive. In addition, through increasing the resources available for research and infrastructure, it will give doctors more incentive to stay and resist the ever-present temptation to seek practice outside of Africa.

Unfortunately, partnerships such as the one suggested by Dr. Dubowitz require financial support from academic institutions in the U.S. that are not necessarily focused on sending professors and doctors abroad to take part in programs at a more meaningful and significant level than the currently accepted “medical tourism” model that takes place. Similar to other facets of our healthcare system that tends to neglect populations that show little economic return on investment, there is little financial incentive for academic institutions to create positions solely devoted to working and training physicians abroad. However, in many eyes, if this shortage is to be fixed and the mortality rates improved, more institutions will need to make just that commitment. Within our current system, there are many professors and researchers at UCSF trying to make things work, to find solutions to problems such as anesthesiology in Africa. The only question that remains is whether or not universities such as UCSF can make the financial commitment to support some of these great ideas when they are presented.

Willieford Moses is a first-year medical student.

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