A two-way street

You can cite the right statistics. You can read the New York Times over morning coffee. But stepping up to the operating room table while the sweat drips off your forehead?

As colleagues in low-resource settings know, that’s when unsafe surgery gets personal.

UTH_Lowri Bowen_Zambia2014

Just ask Steve Brosnan and Corinna Matt, consultants from the Luton & Dunstable University Hospital in the U.K. who spent three months at the University Teaching Hospital (UTH) in Lusaka, Zambia.

“The complete lack of 20ml syringes isn’t much of an issue,” Steve wrote to his department. “What is more of an issue is the search needed to find basic airway equipment and a properly working suction. The theatre oxygen supply is an exercise in patience, and constant vigilance is required.”

But as last year’s under-appreciated report from the All-Party Parliamentary Group on Global Health points out, there’s a mutual benefit to overseas volunteering.

Improving Health at Home and Abroad builds its case around a globalised reality: “We are now all connected and interconnected at every level: facing the same risks from pandemics and non-communicable diseases, relying on the same health networks, and sharing the same commitments to international development.”

When challenges faced by operating room teams across continents vary so wildly, everyone has something to give and something to learn.

In the classroom__UHT 2014_Zambia

The APPG report focuses on three recommendations: spreading good practice, creating a movement and providing the right environment to sustain success.

Steve and Corinna were involved with a number of projects that are doing just that!

Workshop_flyer_UHT 2014_ZambiaThey taught trainees on the MMed physician anaesthesia programme, supported by the Zambia UK Health Workforce Alliance, THET and DFID. The aim is to build high-level anaesthetic capacity across the country – as vital a priority as increasing the number of surgeons, but not always given the same attention.

They helped to run a SAFE Obstetric Anaesthesia Course (like the ones in Uganda and Rwanda), developed by our co-founder the AAGBI and supported by THET, training non-physician anaesthetists in managing the leading causes of maternal death in low-resource settings.

And they worked with Zambian colleagues and Lifebox friend/long-term UTH faculty Dr Dave Snell to deliver the first phase of a country-wide oximeter and safer surgery rollout!

Receiving oximeters__UHT 2014_Zambia

Even at UTH, the largest hospital and a referral centre for the entire country, this takes planning.  We started in November.

For expected items – a to-do list, a budget, a venue; and for unpredictable items, say, customs clearance negotiations for a 50kg shipment of pulse oximeters…

Ready for teaching_UHT 2014_Zambia

…so that, come February when the delegates arrived, things were ready to go.  More than 40 from all over the region were welcomed by the faculty, by the Dean of the Medical School and by the Permanent Secretary to the Minister of Health.

The workshop was a great success. Corinna reports that everyone, from the nurses through to the trainee surgeons, now knows how important the oximeter is.  They listen for the beep and the falling pitch, taking evasive action as soon as a patient’s saturation dips.   The MMed anaesthesia trainees are bringing safety out into the recovery areas, sitting with post-surgical patients as they write up case notes.

St Francis Katete_Zambia_Lifebox in OR_2012

There’s another course planned for October in Livingstone, and two more next year. By the time the courses are finished, every anaesthetic clinical officer in Zambia will have training and access to essential oxygen monitoring.

These are big numbers, just ripe for a big political speech.

But that’s not what the Permanent Secretary did.

“Instead of making a long speech, he got all of the delegates to stand up introduce themselves, saying where they were from,” explained Steve. “It was only then that I realised that a lot of delegates had come a long way to be taught by us.”

Zambia delegate map

As we said at the top – and as Steve and Corinna, who started off with three months sabbatical and now can’t imagine not being part of the next three courses, will tell you – unsafe surgery gets real personal, real fast.

And that’s why we know that it’s going to change.

The crew__UHT 2014_Zambia

 

 

 

 

Together to Liberia

Read all about it!  Read all about it!  Two teams of anaesthetists working in Liberia join forces to provide training for over 50 nurse anaesthetists!

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When news from Liberia goes international, the stories aren’t often positive.  We think that’s because they’re reporting the wrong ones.  There are plenty of positive readallaboutits if you allow for stories that matter more than they shock.

Liberia_boxes of books_2013

Like the recent anaesthetic conferences held in Phebe Hospital, Bong County and JFK Hospital, Monrovia.

Two U.K. groups  we’ve worked with before – Mothers of Africa, who took Lifebox to Liberia last year and the ACTS team, who’ve delivered oximeters and training in Togo,  Gambia and Guinea – flew out to West Africa where they worked together to deliver pulse oximeters, paedaitric probes and training to nurse anaesthetists working in some of the most challenging hospital conditions in the world.

Everyone did a fantastic job!

Liberia_delegates with oximeters_2013

Safe anaesthesia in Liberia is a challenge.  An overworked and ageing cadre of two dozen nurse anaesthetists is responsible for the sedation and pain management of – readallaboutit – 3.5 million people.

Liberia_don't stop the women_2013

But they’re doing incredible work.  The visiting teams were delighted to see, on a visit to Redemption Hospital in Monrovia, the head anaesthetist produce a completed Lifebox logbook.

Turning the well-thumbed pages it’s clear that the oximeter, which was donated last year, is not only regularly used, it’s intelligently used and integrated into the safer practice of anaesthesia.

Liberia_Redemption logbook_lowres2

Page after page of patients who were safely monitored during their surgery, who were given a chance to get off the table with their life back under control.

An additional 26 pulse oximeters were distributed alongside training as part of this trip.  Each one will make a difference to thousands of patient lives in the coming years.

Liberia_oximeter handover_2013

But the team identified the need for further donations still.  There’s the news.  Now we’ve read it.  What are we going to do about it?

 

Before and after

“To make people count, we first need to be able to count people,” said then WHO Director General Lee Jong-Wook in 2003/last week on the excellent Guardian Global Development Professionals Network.

If only ‘counting people’ was as easy as 1,2,3.  Good data gathering takes planning, it takes money, and it takes time you really don’t have at a busy hospital in a low-resource setting country.

Theatre list_Guinea

So it can be difficult to measure the impact of a programme, something programme people hate.  It’s not about vanity – it’s fundamental to know that an intervention is happening in the right place, with the right people, and that it will be needed, wanted, effective.  (Otherwise there’s a good chance that it is about vanity.)

That’s why data is so powerful.  It’s easy enough to vaguely imagine that access to surgery in Sierra Leone, a country ranked 177 out of 187 on the UN Development Index is ‘bad’ – but how bad, exactly?

Specifics spur action like nothing else; after all, it wasn’t just a ‘pretty face’ that launched a thousand ships, it was one face in particular.

Tired_Guinea

Thanks to a door-to-door study by Surgeons OverSeas (SOS) in Sierra Leone, we know that about 25% of the population has a surgical condition that needs attending, and 25% of deaths in the preceding year might have been averted by timely surgical care.

The study, explained one of the authors Dr Adam Kushner, is a first step toward mobilizing the World Health Organization, the U.S. government, foreign governments, and others in the global health community to address this dire need.

Now, you might remember Dr Eva Hanciles-Roberts, one of five medically-qualified anaesthetists in Sierra Leone, who came to visit us in the Lifebox London office last year, in dazzling colours that ignored the rain, and told us about the equipment issues – including high-tech monitors without batteries to make them switch on – she and her team faced.

Dr Eva Manciles-Robert demonstrates the pulse oximeter (in colour-coordinated style)

Dr Eva Manciles-Robert demonstrates the pulse oximeter (in colour-coordinated style)

That March, we worked with her to deliver training to the country’s 60 nurse anaesthetists at Connaught Hospital in Freetown.  Eva helped us distribute enough pulse oximeters to ensure that there was one in every hospital.

But what difference did it make?  Was the monitoring situation so very ‘bad’ before?

It so happens that in 2011, a British medical student called Hareth Bader flew out to Freetown to spend his elective placement exploring the level of intraoperative monitoring available at Connaught Hospital.  He used the Lifebox logbooks to record operation type, anaesthesia used and availability of blood pressure and oximetry during operations.

“Appropriate monitoring of patients is compulsory during surgery and something we take for granted in the United Kingdom,” he told us later, echoing Eva.  And the data.

Of the 46 operations he logged, 43% had no oximeter available, and 23% only intermittent availability – and this at the country’s teaching hospital, in the capital city.

“Surgery continues to be practiced with inadequate monitoring in Sierra Leone, with intraoperative complications such as cardiac arrests and poor early recognition of problems,” he wrote.

Hareth had taken a pulse oximeter, donated by the AAGBI, and after introduction he reported that 100% of the next round of operations he logged were being monitored with continuous pulse oximetry. (You can see the poster presentation from the AAGBI’s GAT Conference here.)

“If mortality is to improve, oximetry must be more readily available.”

Training at Connaught2

c/o Hareth Bader

A year down the line, and Eva, who is in regular contact with the anaesthesia providers she trained, can tell us what a difference more ready access to pulse oximetry and the Lifebox training workshop is making.

“Complex surgery is still referred to Freetown,” she told the British Medical Journal “But nurse anaesthetists who work outside the capital report they now carry out their work with more confidence.”

And all of the donated oximeters are still in place.  She counted.

SLANA_oximetry_recipients

Science without borders, numbers with intent

Preeminent sword-swallowing toxico-nutritional neuro-epidemiologist Hans Rosling just leapt on the table.

MSF_Hans on table_1

Gymnastics in service of illustrating a point (and charming the crowd) during his keynote speech at the Médecins Sans Frontieres (MSF) Scientific Day in London last Friday, and he’s waving his arms enthusiastically.

MSF_Hans on table_2

Intelligent data can do that  – draw insight and outrage from dense statistics, and make you want to stand 10 feet tall so people can see what you see.

For instance a better view of the impossible equation facing the ministry of health in Vietnam today, which Hans challenged the audience to balance: a disease panel equivalent to America in the 1980s divided by the resources of the U.S. economy in the 1960s, multiplied by popular demand for 21st century technology.*

Answers on a very large postcard.  Please.

Or the view from Lagos State, Nigeria, where the maternal mortality ratio is 545/100,000 live births (one of the highest in the world, compared with 8.2 in the U.K., 16.7 in the U.S.). That’s bad, but sub-regional data focuses the binoculars, and  it gets much worse: MSF research has shown that in two of Lagos’ urban slums, the ratio is nearly double – a sinkhole of a crisis unseen except by those who are falling in.

Responsive and responsible statistics can give vulnerable populations a table to stand on, and global health workers a more effective place to begin.  They can help allocate resources and advocate for change.

In other words – heck, in Bill Gates’ words! – measurement matters.

So say the professionals – so says Lifebox – and so says MSF, whose Manson Unit aims to use medicine, lab work and epidemiology to identify developments in the management of medical issues and help MSF field projects to put these changes into practice.

MSF_audience suvey_pre

“What is the most important next step in improving research IMPACT in MSF?”

And our audience survey says:

MSF_audience survey_post

Make sure all MSF research is freely accessible to everyone, by publising in open access journals (39%)

MSF has been presenting research findings at its yearly scientific conference since 2004 (holy archives!) and seems to aspire to a central message: to make a useful impact in global health, we have to listen.

Listen to patterns, listen to colleagues, and most obviously listen to the needs of those groups we are trying to support against a vastly unequal setup.

“Do we actually know the people in the refugee camps?  Do we know their needs?” asked Philipp du Cros, head of the Manson Unit.

MSF programme 2013

For MSF, this has most recently meant investigating reports of excessive deaths in young children in Zamfara State, Nigeria, and joining a multi-agency response to treat the lead poisoning caused by small-scale gold mining; implementing a voluntary reporting system for medical errors in its projects to improve systems (such as increased use of the WHO Surgical Safety Checklist) without allocating blame; following up on reports of death due to ‘yellow eye’ in South Sudan and acting to address the Hepatitis E outbreak (often first identified by acute jaundice), in real time.

MSF_epidemic curve and response

Open access was a happy feature of the day, with support from PLOS (the Public Library of Science), dynamic Twitterlogue, and all presentations available online here.

Even more boundless was the audience that followed online, joining in the conversation via live streaming from 92 countries wordwide.

MSF_countries online

The boundaries between research, advocacy and resources are blurry, and objectivity requires a stance that doesn’t leave much room for compromise.  So there was criticism on Friday, too, but that wasn’t our takeaway message.

The primary concern of any global health initiative needs to be a constantly renewed understanding of the reality of the situation, so that we have a chance of successfully addressing it.  If we don’t ask, regard, review, how do we know?

There are a lot of people listening.  Let’s ask them.

– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – –

*See Hans Rosling’s 2006 TED Talk, ‘Stats that reshape your worldview’.  And his curated 5 TED Talks on global issues here.  And his conversation with Partners in Health.  In fact, why don’t you go for a Rosling ramble – good for your circulation, and we’ll be right here when you get back.

A medico-maritime life for me

If it looks like a ship and it sails like a ship and makes sounds like a ship…it’s probably a floating hospital.  At least if it’s the one that belongs to the charity Mercy Ships, currently docked in the Port of Conakry in Guinea, West Africa.

Photo 1_ship

Bon jour! (The port approach is a lot wetter than starboard entrance)

The MV Africa Mercy is the largest charitable hospital ship in the world, providing free surgical services (primarily facial reconstruction, benign tumor excision, cataract removal and child orthopaedics) to the African countries Mercy Ships visits on a rotating basis.

Photo 2_map

Pre-Very Useful Bridge

A repurposed Danish passenger ferry, she took to the seas in 2007 after a very useful bridge built between coasts en route, put the 16,500-ton vessel on the job line.

About 400 long-term staff, 200 local day workers and a rotating crew of volunteers – surgeons, anaesthesiologists, nurses, radiographers, technicians, engineers, administrators, cleaners, cooks, carers, families, officers and of course a captain – are paid up members of this unique medico-maritime community.

(Actually staff pay their own way on board – although the volunteer-staffed Starbucks is generously subsidized by the mermaid herself.*)

This week, by gracious invitation, Lifebox is finding our sea legs too!

Photo 3_oximeters

We’ve joined the faculty of the Anaesthesia Care Team (ACT), led by Mercy Ships international board member Dr Keith Thomson (who, alongside his team, delivered our pulse oximeters to Togo last summer), for a three-day training course at Donka Hospital – one of two national facilities, both in Conakry, and the largest hospital in Guinea.

We’re ready to join about 60 anaesthesia providers and midwives for two days of lectures, workshops, quizzes and dancing (possibly we’re not 100% ready for the dancing? But you should be!) in essential anaesthesia and midwifery techniques, followed by a day of the WHO Surgical Safety Checklist and pulse oximetry.

Photo 4_ACTs

And we’re very excited for the donation of French-language pulse oximeters to outfit the six hospitals represented at the course, donated with the proceeds from Dr Keith’s recent half marathon adventures!

The Africa Mercy usually spends ten months in each country it visits, wending along the West African coast and ducking back to the Canary Islands in between for repairs.  This is her first trip to Guinea but the charity’s third, following two prior visits from the MV Anastasis (nee Victoria).  She arrived in August, with six operating rooms and nearly 80 patient beds to house the patients eligible for surgery.  Many thousands have shown up for screening, and the lists will stay full until the ship pulls out of port this spring.

Guinea is a low-resource country, but isn’t resource-poor: as the world’s top exporter of bauxite, a key component of aluminium, it sends mini-mountain ranges out of the port regularly.

Photo 6_bauxite

The islands are lush and the sea is fish-blue.

Photo 7_lush Guinea

But the post-colonial legacy and ongoing conflict has been disastrous for most of the 10 million people who live here now, heightened by refugees and tensions from neighbours including  Sierra Leone and Mali.  Guinea most recently ranked 178 out of 187 on the UN’s Human Development Index, with just 1.6 mean years of school for adults and a life expectancy of 54.5 years.

There are only four medical anaesthetists in the entire country, and no standardized programme for anaesthesia training whatsoever.  The doctors here have studied in France, in Moscow; the technicians have learned on the job. There isn’t a single working pulse oximeter in the main operating block in Donka.

The unmet surgical need is vast.

P1010784

An operating room at Donka Hospital

Over the next few weeks we’ll be sharing stories from the ship, from the dedicated crew, from the fabulous ACT team – and from the patients.  They are still queuing up in the hot sun on the dock for screening, often alone and from far up country, in the hope of a life-changing operation they’ll not find anywhere else, from a ship that – with the best will in the world – was built to sail away to another port in need.

Sail away

 

Women in the workplace

Over breakfast at the SAFE course/Lifebox training in Rwanda a few weeks ago – bread, boiled eggs, thick black coffee and milky African tea –

Breakfast

It’s always nice to see what people have for breakfast

– a male guest at the Dereva Hotel was heard to inquire:

“Tell me, why it is that women dominate anaesthesia?”

Was that a glint in his eye or not?  Either way, he had a point – to a point.

There’s limited evidence of female domination in the higher echelons of the healthcare profession, i.e. medical anaesthesia.  The road through medical school to specialization is male-dominated, and although there are two female residents in the current first year cohort of the anaesthesia programme at CHUK no women have graduated since it launched in 2006.

Female residents_CHUK

Professor Angela Enright with the two female trainees at the CHUK anaesthesia programme

But the anaesthesia technician profession is different.

All techs graduate from the same three-year programme at the Kigali Health Institute (KHI), which was set up in direct response to the crisis-point shortage of healthcare workers in Rwanda.

They are trained in the practicalities of anaesthesia, and only the essentials of physiology necessary for the job at hand. KHI has trained about 30 anaesthesia technicians a year since the programme began in 1996, and there are now about 160 working in Rwanda.  Although the medical anaesthesia programme is no longer nascent, techs far outstrip the number of medical graduates at present.

Resus_SAFE

Practicing patient resuscitation at the SAFE course

So their responsibilities are vast. Techs look after the operating rooms; they do emergency resuscitation (trauma, shock, cardiac arrest).  In rural areas, they can end up with cases even more complicated than a medical anaesthetist at a teaching hospital would be faced with, alone.

And because applicants must have completed a science qualification to be eligible for the programme, with the majority coming from nursing, demographics mean that a high proportion of techs are women.

Resus 2_SAFE

“I had to work all hours!” explained Jeanette Kayitesi, an anaesthesia tech in Kigali, reminiscing about her first job in a small city hospital where she was the only anaesthesia technician.  “They always came to get me.  They came to get me in the middle of the night.  They came to get me on maternity leave…”

Domination?  Maybe not.  But it’s certainly a dramatic change from the position of women in Rwanda a generation ago.

Women at SAFE

La DOMINATION at the SAFE course

“In the past, they didn’t like it when a married woman kept working,” explained Mediatrice Usabye, an education director from southern Rwanda, who was in Rwamagana for a conference.

“People saw a woman as someone to marry, to raise children; if a family had a boy and a girl, the boy was the one who went to school.

In the classroom_SAFE

“But after the genocide the government realized there was a disparity between male/female education, and a gender imbalance in all domains.  Now things are changing.  They’re working to close the gap.  Women have paid maternity leave (one month in the private sector; three months in the public sector).”

Today, the rector of KHI is a woman.

KHI_rector

Dr Chantal Kabagabo, Rector of the Kigali Health Institute

So is the anaesthesia department head at the National University of Rwanda.

Christine

So is the Minister of Health.

MOH

Dr Agnes Binagwaho, Minister of Health

That doesn’t change the fact that the reason women appear to ‘dominate’ in anaesthesia, sir, is partly because they are encouraged to train as nurses, not doctors.

“You may ask me why that is,” said Mediatrice, imposingly.  “It’s because so many books are written in Rwanda, especially in primary studies…they show pictures.  Pictures of women as nurses and teachers.”

CHUK_OR

Anaesthesia providers pose outside the operating theatres at CHUK

But Rwandan women are writing their own stories long after they finish primary school.  Take Jeanette.  She recently finished her Masters in Public Health (MPH), and wouldn’t be satisfied, she explained, if she didn’t keep learning and working.  She likes her job as an anaesthesia tech because her day is never the same twice.

She also has five children, aged between 12 and three.

At first her husband nagged when she carried on working after they were married, after their children were born.  Why did she have to take further studies?  Why couldn’t she stay home with the kids?

And now?

The magnificent Jeanette

“He’s so proud. Now when we’re out, I hear him on the other side of the room, telling strangers about my job.  Well, he says, my wife…

Happy International Women’s Day!

 

 

Thank you

They say that the recession is affecting charitable giving.

We say, have you met the readers of the British Medical Journal.

Over the last two months, a stationer’s rainbow of envelopes has greeted our mornings and a rush of online donations have cheered our afternoons (sometimes we actually cheered!)

Generous readers have raised more than £26,000 for Lifebox.

Rwanda_oximeter training

That’s more than 160 pulse oximeters for hospitals in low-resource settings currently delivering surgery without this essential monitoring.  That’s spare probes to extend the life-saving lifespan of the oximeters, and training for anaesthesia providers to ensure that the equipment is used to its fullest, essential function.

We are enormously grateful to everyone who gave – familiar friends from the previous year’s campaign, new names we are delighted to get to know, and every modest Anonymous in between, to whom we are immodestly thankful.

We’re equally grateful to the BMJ for this opportunity.  We’ve worked hard with staff at the journal to show you why your contribution is needed, and what your generosity allows us to do.

BMJ_landing page_screenshot_thanks BMJ

You’ve helped us effectively turn the lights on for anaesthesia providers in Togo, with a donation of 113 oximeters – enough for every operating theatre in the country:

“Before he had a pulse oximeter he felt like an airplane pilot without a radar,” our colleague explained of one of the nurse anaesthetists.  “Now he has an oximeter he has a radar; now he can see where he is going.”

You’ve helped strengthen communities, given medical anaesthetists in El Salvador the opportunity to practically support their technician colleagues across the country, making anaesthesia safer for everyone.

Oximetry_training_Rwanda

In the last two months we’ve explored a rationale for pulse oximetry that spans decades, from “another preventable perioperative death in a hospital in central Africa in 1986” without monitoring, to an operation in the same country more than 20 years later where a pulse oximeter from Lifebox directly saved a life.

Experts have taken us behind the scenes to the frustratingly full-and-wrongly-stocked store cupboards at low-resource setting hospitals, and donors and recipients have taken us cross-continents, showing how directly and immediately your donation can make a difference.

Unused hospital equipment West Africa

Every single feature, podcast and blog from the campaign is available here on our website.  We hope you’ll take a moment to browse, and join us in marveling at how widespread and complex the surgical safety crisis can be, and at how many incredible individuals are fighting to make a difference.

We hope you’ll stay tuned this year to see what happens next!

With sincere thanks from everyone at Lifebox.