Once Upon a Landline: putting the global in global health

Back in the late 1990s, an Ethiopian doctor was working with a Norwegian institution to fund a plastic surgery unit at his hospital.

Yekatit 12 Hospital_Ethiopia

When he wanted to speak to them by phone, he’d stay at his mother’s house to use the landline.

When they needed to email him he’d go to the university library, ask the authorised person to connect and print off the message, draw up a handwritten response, hand it over for type, connection, send – and sleep in the library, waiting for someone to come and wake him with the return message.

Fast forward several years and then reverse to a few weeks ago, and Lifebox was hosting a faculty meeting for trainers from Cameroon, Congo Togo, USA and UK.  October and November were  packed months for our safer surgery work, with training sessions at a national conference in Yaoundé, Kinshasa, Lagos, and there was a lot of prep work to do.

The call was confirmed by email.

Teleconference map

Everyone joined over Skype.

After two quick rounds of “hello, hello, can you hear me…?” the agenda got underway.

Someone took notes.

People asked questions.

An hour and a chorus of goodbyes later we had insight, we had enthusiasm, we had a plan.

And everyone slept in their own bed.

Communication is changing.  Radically.  And yes, the cynic says, sure.   Everything changes and everything stays the same; it’s no easier than it ever was to make a difference in global health.  Show me the other plastic surgery units in Ethiopia.

But the cynic always has something to say.  The reality is – of course it’s easier than it was to make a difference!  To work in collaboration, not isolation.  To collect and share data, use it effectively, and send a photo round the world in 30 seconds that brings two faraway faces into each others’ line of vision.

Kibagabaga waiting room

The growing number of institutional links, academic platforms, education forums – the articles, the public awareness that increasingly makes action the imperative, not the anomaly.

Of course there are pitfalls – and there is ego, and there is scope for abuse; and this giddy tone isn’t to deny the full-blown and circling, global surgery crisis.

Quite the contrary – it’s inviting the crisis into our homes, it’s saying that a comfortable distance from chaos and suffering ‘over there’ doesn’t exist any more.

The very fact that you’re reading this blog post.  That you’re connected by proxy to Benson in Cameroon, Fataou in Togo, the Mercy Ships crew and patients in the Republic of Congo.  That you know avenues to get involved, to spread the word.

There is a long way to go.  But we’re excited to be working at a time when there is scope for everything that needs to be changed changing.  For nothing that has been flawed, for too long, to stay the same.

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Great and glad tidings!

Lifebox isn’t a faith-based organization, but you don’t need to tell us twice about the true meaning of Christmas.

Hope and renewal, sacrifice and generosity – looking back at the most popular stories we’ve shared on our blog this year, there’s meaning behind every message, and inspiration to build a better 2014.

Here’s to a year of great and glad tidings!  And our top ten most-read stories:

BBC_screenshot1. Counting to Save Lives: a heartbreaking horror story from a colleague in Uganda about how one of the simplest steps on the WHO Surgical Checklist  – counting swabs – would have saved a life.  This post got a huge boost from our work with the BBC’s Health Check team this summer, thanks to a short video we made with them at our pilot programme at Kibagabaga Hospital in Rwanda.  The accompanying article highlights why surgical safety isn’t just a low-resource challenge – it’s a global concern.

Kristen and Austen2. Honestly, people in love: an oldie, but a grow-old-with-me goodie!  This ‘favourite ever’ story (and the treatment for our global surgery romcom if it ever gets off the ground), shared interviews and photos of couples who used their wedding spotlights to shine a light on the crisis of unsafe surgery worldwide.   They raised thousands of pounds by putting Lifebox on their gift registries, and have inspired other couples to use the power of love to make surgery safer worldwide.

Cake Collage3. Raising the dough: chefs hats off to a phenomenon we never saw coming: the runaway popularity of the AAGBI’s Great Anaesthesia Bake.  The Association encouraged anaesthesia departments around the country to swap scrubs for aprons and host bakes sales to raise funds for Lifebox.  Word spread, more and more teams took part, and the cakes became increasingly anatomically-correct.   To date, the challenge has raised more than £17,000 for safer surgery.  FROM CAKE.  Just think about that.

Mercy Ships4. A medico-maritime life for me: Capacity-building is essential for securing long-term access to safe surgery in low-resource settings.  But in the meantime there are millions of people who need an operation last year, last month, last week, now.  We’re proud to be working with Mercy Ships, the world’s largest floating hospital, which docks each year in a different African port and embarks on an intensive surgical rota that gives life and livelihood back to thousands of people.  Click here to read about our stay with them in Guinea.

Haydom_oximter on finger5. Man v Machine: the ‘equipment graveyard’ – warehouses full of unusable and unrepairable equipment that so often haunt hospitals in low-resource countries – is a stark failure of international corporations, communities and common sense.  Karoline Linde, at Haydom Lutheran Hospital in Tanzania, wrote to tell us about a day in the life of a Lifebox pulse oximeter – and the challenges, decisions and constant pressure that equipment and healthcare workers are under as they strive to save lives on the front line.

OR staff Kibagabaga

6. Change we can believe in: In 2006 there was just one medical anaesthetist in the entire country of Rwanda.  Today there are 20.  We’ve spent the last year working with Canadian and Rwandan anaesthesia colleagues to deliver oximeters, training and support to this growing community, and the nurse anaesthetists who share the burden.  We’re so proud to stand alongside colleagues so deeply invested in the country’s painful and dramatic capacity to heal itself.

Guheka_low res

7. Riddle me this: What do you call an operation that saves two lives at once?  A caesarean section.  Safely deliver a struggling baby from a mother locked in obstructed labour for days and deadly weary, and you’ve pulled two lives back from certain brink.  But lack of access to surgery is a crisis compounded by the crisis of unsafe surgery.  We took a look at the perils of obstetric surgery in low-resource settings, and some of the new organizations and programmes that have been developed to address them.

Teleflex ad

8. I left my heart in San Francisco: As some loud-mouthed puppets wisely said, ‘You need a montage” – so we had a lot of fun making one of our recent trip to San Francisco, for the American Society of Anesthesiologists’ annual conference.  We met colleagues from around the world, worked with the ASA’s Global Humanitarian Outreach committee to deliver a session on Lifebox training in the field, and were the lucky beneficiaries of Teleflex’s ‘play it forward’ game.  And oh, you should have seen those skies…

9.  Before and After: a hymn to the numerical imperative!  “To make people count, we first need to be able to count people,” said a previous WHO Director General – and Bill Gates (who made a whole video about it).  We took a look at the value of measurement in our programmes, following up with Dr Eva Manciles at Connaught Hospital in Sierra Leone, to see what difference the oximetry distribution and training had made in the last year.  We hope you’ll be just as excited as we were by the results.

 

C-section10. The World We Want 2015: It’s a magnificent proposition.  Go on: design the world you want your children to grow up in.  Just remember that you can’t choose their sex, their race, their long- or latitude.  And you don’t know their characters, their ideas, their – well, you don’t know anything about what they really want, do you?  You just need to know that, wherever or whoever they are, they’ve got the best shot at a life and let living.  Join Lifebox as we enter the essential fray of post-Millennium Development Goals debate, and make our case for safe surgery as an essential component of healthcare in the framework that follows in 2015.

And that’s barely a wrap!  There are so many more stories to hear and people to meet that we humbly suggest, if you find yourself a little wearied by this festive time of year, nab a quiet corner and a wifi connection, and go fishing at www.safersurgery.wordpress.com

We’d love to hear from you about your favourite pieces!

Returning to the spirit of the season, we can’t avoid a closing plea.  With only a few days to go, your presents are probably wrapped and ready for fetching from under the tree – but there are some gifts that last long after the box is gone and spring feels closer than Christmas.

Holiday Giving Guide

Donate to Lifebox in someone’s name.  It’s easy to give the gift of safer surgery – just follow the instructions below, and we’ll let them know that they have received – and given – a life-saving present this year.

With sincere thanks, and our best wishes for a very happy holiday season and a joyful new year to you and yours.

The Lifebox Team.

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!

DSC07675

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?

 

Approaching thankfulness

There’s a lot that we aren’t thankful for this year.

High risk of anaesthesia mortality; low chance of getting a C-section when you need one.

Warehouses full of inappropriate medical equipment, operating rooms bereft of the most basic, functional devices.

But if we only read the starkest statistics, told each other the bleakest stories, we’d give up.  Dress the turkey in our baggiest clothes and send it in to work, because what’s the point of trying.

Sorry to disappoint you, turkey.  Not one single person we have met this year has given up.

Far from it – we work with colleagues who are so dedicated, traveling hundreds of miles, working weeks melting into years on end to raise the standard of surgical care in their hospitals, that sometimes it’s hard to believe that the statistics are true.

OR_Balkh General Hospital_Afghanistan_2012 (2)

And we’ve had such generous support from donors around the world, challenging themselves in every forum to raise funds and awareness of the surgical safety crisis that, though it statistically remains “the neglected stepchild of global health” it feels like we’re part of an extended family devoted to ending that neglect.

NewJerseyMedicalSchool-Follies2013

It’s not Thanksgiving everywhere today, but we wanted to take the opportunity to join in the spirit.  Yes we’re dissatisfied with the way the world works, and yes there are things we want to change.  But we work with people every day who are doing just that: teaching, giving, sharing, saving (all the best parts of the Thanksgiving story and none of the bad ones), and we are humble and grateful for it.

To all our colleagues around the world who are celebrating today, cheers to turkey and thankfulness!  And to all those who are working to make surgery safer, and to bringing this life-saving, vital healthcare component to those who need it – thank you!

Thankful_Guinea

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.

Harbour

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:

Booth

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

Steppe-by-Steppe: Safer Surgery in Mongolia

The Make It 0 campaign is global, but it works on a very neighbourly basis!  It’s great to see colleagues from high and low-resource setting countries working together to deliver training and equipment where it’s needed.  Most recently, the Australian and New Zealand College of Anaesthetists (ANZCA), the Australian Society of Anaesthetists (ASA) and the Mongolian Society of Anesthesiologists (MSA) delivered the first Lifebox training and distribution project in Mongolia.  

Dr Simon Hendel, an Australian anaesthetist who wrote about Lifebox last year for the Global Health Gateway (click to read ‘Making It Zero in the Real World‘), was Our Man in Mongolia and kindly sent in this report…

Mongolia view

Being largely ignorant of Mongolia and its history prior to going there, my notions of the country were no more formed than clichéd ideas of Chinggis Khaan merged somehow with years of Soviet occupation. I had prepared myself for boiled mutton fat washed down with homemade vodka for breakfast lunch and dinner. I couldn’t have been more wrong.

It’s an exciting time for Mongolia and not only for anaesthetists. Sandwiched between Russia and China and rich in mineral resources, Mongolia is in the throws of an economic and social boom, driven largely by the mining industry. This boom has seen vast sums of money injected into the country particularly in the capital, Ulaanbaatar. Whether this injection is good or bad is not for me to say, but it is resulting in massive changes in Mongolia.High end Mongolia

Boutique stores like Louis Vuitton, Hugo Boss and Ermegildo Zegna line potholed roads and the city’s population of urban poor. Like many booms in developing countries, one effect is to highlight the enormous disparity between the haves and the have-nots. Nowhere is that disparity clearer than in the provinces, where providing safe surgical services to the dispersed population remains very difficult.

Which is why it was such a privilege to work with my Mongolian and Australian colleagues to launch Lifebox in Mongolia and see true enthusiasm for making surgery safer.

Dr Ariunbold_Arkhangai Province_Dr Simond Hendel_Mongolia

We met in the Mongolian Society of Anaesthetists’ headquarters – a single room in a block of leased offices, quite fittingly flanked by tech startups. Representative anesthesiologists from each of the 21 provinces and 5 from hospitals in Ulaanbaatar eagerly took their seats around the central meeting table.

Mongolia training workshop 2Led by the president and immediate-past-president of the Mongolian Society of Anesthesiologists, the education sessions reinforced the essentials of pulse oximetry and oxygenation. Together, we interrogated the oximeters and practiced our action plans for low sats.

Mongolia training workshop 3

The day was fun and energetic and concluded with the distribution of an oximeter to each of the attendees. The ASA and ANZCA donated 100 oximeters jointly – 26 were distributed on the day and the remainder will be allocated by the MSA.

Dr Ganbold Lundeg_MSA president centre_Dr Simon Hendel left_Dr David Pescod 3rd from left_Mongolia

I’m an anaesthetist from a place where oximeters are taken completely for granted, expected by all to be accurate and available. It was humbling to work with colleagues who saw the life-saving value of this piece of equipment. I hope I’m not blasé about the “beep-beep” sound in every single theatre, recovery cubicle and ICU bed when I go home.

Mongolia on the road

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.

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*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.