I left my heart…

…in San Francisco,Arrow heart

where the American Society of Anesthesiologists (ASA) held their annual conference this year.

Trolley car

“How beautiful!” everyone back home told you.


But you probably spent most of your time here:

Moscone Center

Never mind the early starts…

Coffee cup

…we  had a great time!

Dr Alex Hannenberg and cheque

But then, we had the best seat in the house – a beautiful booth alongside our friends at the ASA’s Global Humanitarian Outreach (GHO) committee:


With special shout out to the AAGBI’s Great Anaesthesia Bake:

Great Anaesthesia Bake

A Lifebox trustee on the front page of the ANESTHESIOLOGY 2013 Daily News:

Daily News_arrow

And a training workshop on how to implement safe surgical practice in a low-resource setting that inspired real conversation…

Lifebox workshop ASA

…so much conversation that we couldn’t get people to sit down again between sessions.

Lifebox workshop ASA 2We found a good home at a hospital in Nigeria for some oximeters:

Oximeter handover_ASA

and a friend to help carry them there!

Carrying oximeters

We felt like the sun was rising every time we saw this ad across the big screen…

Teleflex adand are enormously grateful to Teleflex, who gave a whole new purpose to trivia and presented us with this giant gameshow cheque.  It means real life change for surgical patients and providers in low-resource settings.

Teleflex presentation

(And comes it its own giant gameshow cheque box.)

Teleflex box

It felt good to work with the ASA as friends and allies for safer surgery, with our upcoming projects in Nicaragua and Guatemala, and the announcement of the First Annual National Lifebox Challenge led by the Residents Component.

Central American project

So even though we had to go home, we took the ASA’s advice –

Be Social

– and told you all about it!

It really was pretty.

SF from the air


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.


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


Vanderbilting bridges: from Tennessee to Kenya

Members of the Department of Anesthesiology at Vanderbilt University School of Medicine, Tennessee, don’t need to be told about the critical state of anaesthesia in low-resource settings – lack of providers, scarcity of the right drugs and equipment, the shocking mortality statistics  – thanks to the Vanderbilt International Anesthesia (VIA) programme, many have seen it for themselves.

Check out the video on the VIA home page, which focuses on Vanderbilt’s relationship with the Kijabe Hospital, in Kenya.  Panning down crowded hospital corridors, the images are stark and the voices are shocked.

“What do you do with a girl that needs a caesarean section?” VIA director Dr Mark Newton recalls asking a clinician at the hospital. “He said rather nonchalantly, ‘she just dies.’

“She just dies.”

But things are changing.  Kijabe Hospital sees 10,000 cases a year: that’s a lot of medical provision, and a lot of opportunity to teach. Newton splits his time between paediatric anaesthesia at Vanderbilt and chief anethesiologist duties at Kijabe, where he has developed a nurse anesthesia training programme.  Training nurses to deliver anesthesia is particularly important for rural areas, where lack of anesthetic provision is a constant crisis.   He’s assisted by Kenyan faculty, and medical staff from Vanderbilt who visit Kijabe (and a number of other sites in low-resource settings worldwide) to train, educate and learn.

The American Medical Association Foundation (AMA) took notice of Vanderbilt’s work and Newton’s travel schedule – in February they awarded him an Excellence in Medicine Award.  As well as the grand title, this award came with a cash prize, and Lifebox was thrilled when Newton asked to spend his award on pulse oximeters for Kenya!

“We can directly save lives with a mere $250 pulse oximeter which is designed for the rugged environment of Africa,” Newton told the AMA Foundation Quarterly last month.

10 oximeters touched down briefly in the U.S., before setting of for East Africa, where they are already hard at work – but this is only the beginning…

The Department of Anesthesiology will soon begin a fundraising drive to purchase additional pulse oximeters.  “Our target for the 2012-2013 academic year is to purchase a minimum of 200,” explained Dr Newton.  “Our graduating Kenyan Registered Nurse Anesthetists can then take these devices with them to use as they provide medical care throughout their careers.”

Vanderbilt Anesthesiology Chair Warren Sandberg, and residents Drs. Joseph Schlesinger, Brett Campbell, Jace Perkerson, and Justin Wright with some of the first pulse oximeters to be sent to Kijabe, Kenya, for use in the field.

“We are thrilled at Lifebox to be working with Vanderbilt University to provide pulse oximeters and essential training to anaesthesia providers in Kenya,” said Lifebox chairman, Dr Atul Gawande.  “They face critical gaps in resources and knowledge, and this work will save lives.”

A Nice Complement

An anaesthesia machine and a pulse oximeter are the Fred and Ginger of the operating room.  Working in synch, the first enables surgery to take place, while the second gives the provider time to act should an adverse incident put them on the back foot.

(c) MusMs

So it was a nice collaboration when Gradian Health Systems, a not-for-profit provider of anaesthesia machines for low-resource settings, recently bought 20 Lifebox pulse oximeters for each of its UAM machines, currently in facilities across Nepal, Malawi, Nigeria and Ghana.

In a surgical setting where electricity may be unreliable and even essential equipment scarce, it is imperative that devices can withstand their environment.  The best equipment is useless if it’s inappropriate for the setting, and unfortunately too many pieces of equipment sit on warehouse shelves in low-resource facilities, far from the patient and provider.

But both the Lifebox oximeter and the UAM are specially designed for the low-resource setting.  They can be put to work immediately, and they function long-term.  And the feedback from recipients has been fantastic.

“Be assured that this oximeter will save lives amongst the 130,000 people who we are serving within and beyond our catchment area,” said an anaesthesia provider at Mua Mission Hospital in central Malawi.

The road up to St Anne’s, trod down by an enormous catchment area

“The Lifebox pulse oximeter is nice and working well. The other good thing is that it has got a rechargeable battery,” explained a doctor at St. Anne’s Hospital, also in Malawi.  “We had one pulse oximeter, we were using one more in the children’s ward, but it stopped working 2 months ago.”

The recovery room at Kamazu Central Hospital, Malawi

The education programme that is a fundamental part of the Lifebox Foundation mission to improve the safety and quality of surgical care, is equally important.

“The oximeters arrived in perfect time,” said the assistant dean of Bir Hospital in Nepal.  “We are running a course for 14 people today. I’ll be delivering the tutorial, and using the equipment for training and patient care.”

Pulse oximetry training in Nepal

This collaboration is an exciting realization of “a common belief in technology, training and local expertise as the way to increase access to safe surgery,” as Stephen Rudy, Gradian CEO, said.  We can’t wait to see more!

Surgery is aimed at the majority, not the rich

Did you know that a full 11% of the global burden of violence and injury – which occurs overwhelmingly in low and lower-middle income – countries could be treated with surgery?

That’s an incredible opportunity to save lives! And it’s one of the reasons why we need to do something about the fact that the poorest third of the world’s population receives only 3.5% of the world’s major surgical procedures (the richest third receives 73.6%). {1}

At Lifebox we’re regularly shocked by these statistics – but we also see how many people and organizations there are committed to making a difference.  Last Friday we were lucky enough to meet some of them, at the Global Surgical Frontiers Day , hosted by the Royal College of Surgeons.

It was like walking into a party where you want to talk to every single person in the room!

Professor Chris Lavy, who worked as an orthopaedic surgeon for a decade in Malawi, brought together more than twenty organizations of all different sizes to present their initiatives and talk about opportunities for working together.

Some groups, like Aid to Hospitals Worldwide, redress the balance shipping container by shipping container – they send recycled NHS equipment  to ill-equipped facilities in low-resource countries.  Others, like Out To Africa, nurture direct links, pairing colleagues between the Mid Essex Hospital in Chelmsford and the University Teaching Hospital in Zambia to support professional development.

Some, like the College of Surgeons of East, Central and Southern Africa (COSECSA) cross a continent, helping to develop national surgical policy, running training and exams. Others, like Mercy Ships cross waves and oceans, in liners refitted with operating rooms, surgeons and family on board, to perform crucial procedures docked along the coast of Africa.

Like we said, the statistics made our eyes water, and the personal stories – two-year old twins who received cataract operations through Mercy Ships and woke up to see their mother – and each other – for the first time; a gentleman from the Congo eating by himself for the first time in eleven years after receiving prosthetics from Willing and Abel – made our throats catch.

Lord Ribeiro wants YOU to Make it Zero

But we straightened our ties and talked to Lord Ribeiro, a leading figure in international surgery, who spoke about his hometown of Achimota in Ghana, and asked attendees to create an organizational structure that could benefit those who really needed it.

During his speech on the surgical and education work done by Mercy Ships Lord McColl told that old story of the child on the shore throwing marooned starfish, one by one, back into the water – what difference will it possibly make? asks the cynic, with so many of them hopelessly beached ?

Well of course it makes all the difference in the world to the ones that get thrown back, reminded His Lordship.  But he also acknowledged what was special about this conference – figuring out how we can work together in training and education, making a sustainable change, so that people in low-resource countries get the surgical opportunities they deserve – and lives aren’t beached prematurely.

{1} Weiser TG, Regenbogen SE, Thompson KD et al (2008) An estimation of the global volume of surgery: a modelling strategy based on available data. Lancet 372:139–144