Putting anaesthesia on the map

This is a map of where to find fish in Lake Malawi. The 3 million year old basin lapping against the ‘The Warm Heart of Africa”s eastern border has a unique biodiversity of cold-blooded residents.

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This is a map of the voter breakdown during Malawi’s fourth multi-party election, in 1993.

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And this is a map showing the start point of every patient arriving for surgery at the Fistula Care Centre in the capital city, Lilongwe: hundreds of women from dark corners of small rooms in rural villages across the country, living with the permanent incontinence of obstetric fistula. Usually in isolation, locked out of society mourning their baby, their dignity, their place in society.


Maps can teach you a lot of different things, but of course it depends what you’re looking for.

In the last month Lifebox has joined two trips to Malawi, plotting a route directly towards the country’s anaesthesia providers.  Without them the fish will keep jumping and the politicians will keep campaigning – but victims of road traffic accidents will never be stitched up, fistula women will never be dry, and mothers in obstructed labour will continue to struggle and tear and lose their babies and join these neglected ranks.

Unfortunately it wouldn’t take long to put them on the map: there are just a few hundred clinical anaesthetic officers in Malawi, and fewer than five Malawian medical anaesthetists for a population of 16.4 million.  (Compared with more than 10,000 for a population of 64 million in the U.K.)

A small group of visiting medical anaesthetists effectively doubles the country statistics.


In August, Lifebox trustee Dr Isabeau Walker travelled with long-time Lifebox friend and president of the College of Anaesthetists of Ireland Dr Ellen O’Sullivan to Queen Elizabeth Central Hospital in Blantyre, in the south of the country.

They were working with Cyril Goddia, who heads the hospital’s Anaesthesia Clinical Officer training programme.  A survey he undertook last year with Gradian Health Systems revealed a significant pulse oximetry gap.  So we set about a project to close it.

Some anaesthesia colleagues travelled 10 hours to get to Blantyre, from small rural hospitals across the region. They were working without pulse oximeters, or having to share one between two to four theatres.  Basic monitoring was a finger on the pulse and an eye on the colour of the patient’s lips…

Blantyre_workshop_August 2014_team photo

Thanks to the Cycling Surgeons, who took on hill and dale and puncture in the name of safer surgery, to the College of Anaesthetists of Ireland (COI) who led the faculty alongside our Malawian colleagues, we were able to donate 100 pulse oximeters and deliver training to 80 anaesthesia providers and 20 clinical officer surgeons.

“Thousands of lives will be safer as a result of all your efforts,” Dr Walker reported back.  Of the photo from the course – “The smiles say it all!”

Two weeks later we were back in the north, at Kamuzu Central Hospital with ACTS – the African Conference Team led by Dr Keith Thomson. This three-day conference (in the ‘Warm Heart of the Warm Heart’, according to Fanny Mtambo, who supports the UNC Project-Malawi) was an opportunity to improve practice in an area of anaesthetic care that makes up almost 80% of emergency cases: obstetrics.


Think about surgery and (much like toast in a toaster) who comes to mind – the surgeon. But think again about an operation at its most basic level – scalpel rending skin – and imagine it without anaesthesia. It’s the difference between modern medicine and torture, but it’s often overlooked.


This workshop, with support from the Gloag Foundation and UNC, was an opportunity to support the skills, the concerns and the community spirit of a group who know more than any other that something needs to be clear:

“There is no surgery without anaesthesia.”

Explained William Banda,  a medical anaesthetist working at Kamuzu: “You can train 100 surgeons – but there will be no operation.”

This shouldn’t be news – but since the message is still lacking, we’re delighted to see that it was! IMG_6322

MBC TV, the main television station in Malawi, sent two journalists and a camera to the conference, to meet the delegates and shine a lens on the vital role of anaesthesia in safe motherhood.  It’s possible that they zoomed in on more than expected – a visit to the maternity ward moved quickly from theory to practice – and a gown, mask and a brightly beeping corner of an operating room as a baby was born by emergency C-section.

“Bringing life into this world is an exciting experience,” narrates the journalist, “but at times it can be life-threatening…However there is no surgery without anaesthesia, as anaesthetists play a crucial role in an operation.”

The report was screened twice in 24 hours.  What was the response?

“We didn’t know, they say,” explained Marie. “We didn’t know you needed all this to deliver, to survive.”

map_malawi_pointsThis is a map of how far delegates at the Lifebox pulse oximetry workshop travelled to get to Blantyre – making the long journey by crowded bus, by bike, from all over the southern region.  They came to learn about safer surgery, and take an oximeter back to keep their patients safer.

There are so many more maps we need – where pulse oximeters and training are urgently needed next.  Where women wait for fistula repair surgery – or soon will, if they can’t get to a hospital.  Where safe surgery is taking place – and where we support the equipment and training to make it evem safer, so that providers and families aren’t forced to make terrible choices to do their jobs or save the people they love.


Till then we’ll be leaving the fish to mind their own business.










Comic Time Out

Not every comic is meant to be funny. While the Scottish city of Dundee’s classic troublemaker Dennis the Menace always lunged for the elbow, one of its newer residents has gone for the incision.

01_Handiwork title

Handiwork: surgery in sequential art, by Emmanouil Kapazoglou, adapts the comic strip format to tell a serious story that is both strange and familiar.

It follows a typical operation on a typical day for a surgical team at the Tayside NHS Trust. Through the prism of the World Health Organization (WHO) Surgical Safety Checklist, we’re taken on a step-by-step journey of the pulse points and timeframes of a surgical procedure.


Scroll slowly. The panels, as with any comic strip or the boxes on the Checklist itself, can only succeed in linear, deliberate steps.

Handiwork_cartoon strip

First through the photographs and then through illustrations of those real life images, past the swinging doors and under the hot lights.


Watch as the seeming chaos of masked faces and machines reveals its tightly-rehearsed order – and the team’s intense focus on the safety of the one person not expected to play a role, the reason they’re all here: the patient, lying insensate on a table in the middle of the room. 03b_Huddle

You’re completing your masters in Medical Art at the Duncan of Jordanstone College of Art and Design, but this still seems like an unusual subject! What led you to the comic strip and the operating room?

04a_Transport_photoComics are so important in medical education. They have a visual impact and a strong message, but they’re also a helpful generalisation – they can expand the experience of an individual into human experience regardless of gender, age, nationality etc.

They can also speak to the non-medical community, and I was interested to see how they could translate what goes on in an operating room. I wanted to capture the teamwork necessary for a successful surgery. 04b_Transport_paint

What surprised you about the operating room?

How calm it was. Medical dramas on TV make it seem stressful – what a misrepresentation. The OR was such a calm place.

Why did you choose the Checklist?

I wanted to show something constant, and the Checklist is the backbone of how surgery happens nowadays.  I was very surprised to find out how recently it was introduced – and how difficult it is to change certain patterns of behaviour when people have learned to be kings in their theatres.


Did you see it have an impact?

Seemingly small things, like an allergy not noted down – that could have been catastrophic, but the Checklist caught it. The simple communication it allows between the theatre staff, between the anaesthetist and the ward nurse – there’s a human life on the line, it’s essential. 08_Recovery

Did you feel like patients were in safe hands?

The teamwork at Ninewells is inspiring. There’s no place for egoism or career advancement in that room – everything happens for the safety of the patient.

It’s a powerful thing.

Yes, I find that very moving. The vulnerability of the patient under anaesthesia – it’s a person at their most vulnerable, unconscious and surrounded by so many people.

To find that calm mood, and all these people working together – it’s very tender in a way.


Has it changed the way you think about surgery around the world?

I was looking on the Lifebox website and I was shocked – I never thought that lack of oximetry was an issue in so many countries.

You show the Checklist twice, once in photos and once in paint – why is that?

After the second viewing we thought that the pictures might be too intense for someone about to undergo surgery. The drawings are a simplification, and even though they’re the same scenes, people seem to prefer them. There are lots of things you don’t want to know before the operation – other than that you are going to be safe.


They’re very vivid!

I used an impressionistic technique called speed painting where you set a timer, start painting and as soon as the timer goes off, you stop. It makes you keep only the most important aspects of the scene.

How did you relate to the Checklist it as a non-medic?

05b_lightsChecklists happen everywhere. It’s this methodology, a frame of mind behind a sequence of events that shows how teamwork is realised. I used to work as a production assistant at dance festivals – without a checklist we’d never be able to have a performance.

I found the surgical pause particularly poetic. A moment’s thought, everybody stops – it’s like this breath that a performer takes when they go on stage. The lights, the audience, the safety protocol – it’s no joke that the operating room is also called a theatre! 05c_lights


All photos copyright 2014 Emmanouil Kapazoglou, University of Dundee

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.


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!


The World We Want 2015

It’s a magnificent proposition.  Go on: design the world you want your children to grow up in.

World we want

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 and whoever they are, they’ve got the best shot at a life and let living.

Back in 2000, eight priority areas and associated targets were identified to take a generation closer to this fair start: the Millennium Development Goals (MDGs).


(c) US Mission Geneva

With just 2.85 years (and counting) to go until these targets expire, the penalty for missing the mark will be paid by those who they were intended to support.

So we better get the next plan underway.

Lifebox is proud to have submitted a paper to “The World We Want 2015,” a joint platform between the United Nations and Civil Society (that’s you!  And us!) conceived as a forum – or even a movement – for “people all over the world contributing their vision towards an overall plan to build a just and sustainable world free from poverty.”

Our concern is, of course, health; and more specifically, the essential but neglected role that surgery plays in healthcare.


An estimated 56 million people require surgery in Africa alone, resulting in 25 million disability-adjusted life years (DALYs).  There’s no devil’s advocacy in pointing out the fact that this is close to double the number of people infected with HIV worldwide (33 million), a health crisis that has long and rightly been recognized as such. Our paper aims to draw similar attention to the crisis of unmet surgical need in low-resource settings.

Back in 2000, surgery was bundled with the “other diseases” of MDG 6, when in actual fact it’s a tool that can be used to achieve certain targets.

MDG5, for example, maternal health, for example, is a gospel priority, with great improvements made over the last decade.  “But levels are far from the 2015 target.”

One of the barriers is surely a numbers game, with the odds stacked: the recommended c-section rate is 5-15 percent of deliveries, but rates from low-resource countries are drastically lower than this – just 0.6 percent in Ethiopia.  Without broader access to safe surgery, maternal health targets will never be met.


(c) Amber Lucero-Dwyer/Lifebox Foundation

So it’s certainly a big step forward to see the words “surgical capacity” appearing twice in the draft report, released this month as the next stage in the WWW2015 online consultation on health.  This is in reference to the infrastructure required to build national health systems and the “needed services” to meet the goal of Universal Health Coverage (UCH).

And then comes the call for comment.

We strongly echo the response from Jaymie Henry  on behalf of the International Collaboration for Essential Surgery (ICES), which calls for a higher-level of attention to surgery as a primary care component, and the emphasis on training this requires.

We strongly echo the rationale from Kathleen Casey, founding director of Operation Giving Back, who wrote last year in JAMA that  “greater provision of quality surgical care averts lifelong disability, prevents death and ameliorates the conditions of poverty.”

We strongly state that infrastructure and improving access to safe anaesthesia is an essential component of safe surgery, and that this is a universal right.

The back-story behind the development of the first round of MDGs, without denigrating their impact, is rather more back-of-a-napkin than might be expected. (Positives: agile.  Negatives: last-minute corridor dash to include the environment on the list.)

Sequels are usually a more scrutinized story, and this time the consultation is on a massive and laborious scale.  (Negatives: massive and laborious.  Positives: this conversation affects all of us, and we need to fling open the doors.)

Rwanda view

We’ll be watching closely, and joining in where we can.  And we’ll continue to distribute pulse oximeters and training in oximetry and the World Health Organization’s Surgical Safety Checklist, and strive to close the global pulse oximetry gap.  The numerous organizations that have submitted comments to the thematic consultation will likewise continue the work that made them passionate enough about global health to comment in the first place.

Because there’s a long way to go in closing the gap between the world we want and the world we’ve got; we can talk while we work.

Oximeter in surgery