Gerald Dubowitz

The neglect of the global surgical workforce: experience and evidence from Uganda.

BackgroundAfrica’s health workforce crisis has recently been emphasized by major international organizations. As a part of this discussion, it has become apparent that the workforce required to deliver surgical services has been significantly neglected.MethodsThis paper reviews some of the reasons for this relative neglect and emphasizes its importance to health systems and public health. We report the first comprehensive analysis of the surgical workforce in Uganda, identify challenges to workforce development, and evaluate current programs addressing these challenges. This was performed through a literature review, analysis of existing policies to improve surgical access, and pilot retrospective studies of surgical output and workforce in nine rural hospitals.ResultsUganda has a shortage of surgical personnel in comparison to higher income countries, but the precise gap is unknown. The most significant challenges to workforce development include recruitment, training, retention, and infrastructure for service delivery. Curricular innovations, international collaborations, and development of research capacity are some of the initiatives underway to overcome these challenges. Several programs and policies are addressing the maldistribution of the surgical workforce in urban areas. These programs include surgical camps, specialist outreach, and decentralization of surgical services. Each has the advantage of improving access to care, but sustainability has been an issue for all of these programs. Initial results from nine hospitals show that surgical output is similar to previous studies and lags far behind estimates in higher-income countries. Task-shifting to non-physician surgical personnel is one possible future alternative.ConclusionsThe experience of Uganda is representative of other low-income countries and may provide valuable lessons. Greater attention must be paid to this critical aspect of the global crisis in human resources for health.

Global anesthesia workforce crisis: a preliminary survey revealing shortages contributing to undesirable outcomes and unsafe practices.

BackgroundThe burden of disease, disability, and mortality that could be averted by surgery is growing. However, few low and middle income countries (LMICs) have the infrastructure or capacity to provide surgical services to meet this growing need. Equally, few of these countries have been assessed for key infrastructural capacity including surgical and anesthesia providers, equipment, and supplies. These assessments are critical to revealing magnitude of the evolving surgical and anesthesia workforce crisis, related morbidity and mortality, and necessary steps to mitigate the impact of the crisis.MethodsA pilot Internet-based survey was conducted to estimate per-capita anesthesia providers in LMICs. Information was obtained from e-mail respondents at national health care addresses, and from individuals working in-country on anesthesia-related projects.ResultsWorkers from 6 of 98 countries responded to direct e-mail inquiries, and an additional five responses came from individuals who were working or had worked in-country at the time of the survey. The data collected revealed that the per-capita anesthesia provider ratio in the countries surveyed was often 100 times lower than in developed countries.ConclusionsThis pilot study revealed that the number of anesthesia providers available per capita of population is markedly reduced in low and lower middle income countries compared to developed countries. As anesthesia providers are an integral part of the delivery of safe and effective surgical care, it is essential that more data is collected to fully understand the deficiencies in workforce and capacity in low and middle income countries.

Temazepam at high altitude reduces periodic breathing without impairing next-day performance: a randomized cross-over double-blind study

The aim of the study was to examine the efficacy and safety of temazepam on nocturnal oxygenation and next‐day performance at altitude. A double‐blind, randomized, cross‐over trial was performed in Thirty‐three healthy volunteers. Volunteers took 10 mg of temazepam and placebo in random order on two successive nights soon after arrival at 5000 m, following a 17‐day trek from 410 m. Overnight SaO2 and body movements, and next‐day reaction time, maintenance of wakefulness and cognition were assessed. Compared with placebo, temazepam resulted in a reduction in periodic breathing from a median (range) of 16 (0–81.3)% of the night to 9.4 (0–79.6)% (P = 0.016, Wilcoxons signed‐rank test), associated with a small but significant decrease in mean nocturnal SaO2 from 78 (65–84)% to 76 (64–83)% (P = 0.013). There was no change in sleep latency (P = 0.40) or restlessness (P = 0.30). Temazepam had no adverse effect on next‐day reaction time [241 (201–380) ms postplacebo and 242 (204–386) ms post‐temazepam], maintenance of wakefulness (seven trekkers failed to maintain 40 min of wakefulness postplacebo, and four post‐temazepam), cognition or acute mountain sickness. At high altitude temazepam reduces periodic breathing during sleep without an adverse effect on next‐day reaction time, maintenance of wakefulness or cognition. The 2% reduction in mean SaO2 post‐temazepam is likely to be predominantly because of acclimatization, as by chance more trekkers took temazepam on the first night (19 versus 14). We conclude that at high altitude temazepam is effective in reducing periodic breathing, and is safe to use, without any adverse effect upon next‐day performance.

Surgery and anesthesia capacity-building in resource-poor settings: description of an ongoing academic partnership in Uganda.

BackgroundSurgery and perioperative care have been neglected in the arena of global health despite evidence of cost-effectiveness and the growing, substantial burden of surgical conditions. Various approaches to address the surgical disease crisis have been reported. This article describes the strategy of Global Partners in Anesthesia and Surgery (GPAS), an academically based, capacity-building collaboration between North American and Ugandan teaching institutions.MethodsThe collaboration’s projects shift away from the trainee exchange, equipment donation, and clinical service delivery models. Instead, it focuses on three locally identified objectives to improve surgical and perioperative care capacity in Uganda: workforce expansion, research, collaboration.ResultsRecruitment programs from 2007 to 2011 helped increase the number of surgery and anesthesia trainees at Mulago Hospital (Kampala, Uganda) from 20 to 40 and 2 to 19, respectively. All sponsored trainees successfully graduated and remained in the region. Postgraduate academic positions were created and filled to promote workforce retention. A local research agenda was developed, more than 15 collaborative, peer-reviewed papers have been published, and the first competitive research grant for a principal investigator in the Department of Surgery at Mulago was obtained. A local projects coordinator position and an annual conference were created and jointly funded by partnering international efforts to promote collaboration.ConclusionsSub-Saharan Africa has profound unmet needs in surgery and perioperative care. This academically based model helped increase recruitment of trainees, expanded local research, and strengthened stakeholder collaboration in Uganda. Further analysis is underway to determine the impact on surgical disease burden and other important outcome measures.

Effect of temazepam on oxygen saturation and sleep quality at high altitude: randomised placebo controlled crossover trial

Abstract Objective: To determine the effects of temazepam on the quality of sleep and on oxygen saturation during sleep in subjects at high altitude. Design: Randomised, blinded, crossover, placebo controlled trial. Setting: Base camp at Mount Everest (altitude 5300 m). Subjects: 11 members of British Mount Everest Medical Expedition recently arrived at base camp. Intervention: Participants were randomly allocated to receive either temazepam 10 mg or placebo on their first night at base camp and the other treatment on the second night. Main outcome measures: Quality of sleep (assessed subjectively), mean arterial oxygen saturation value, and changes in saturation values (as measure of periodic breathing) while participants taking temazepam or placebo. Results: All participants noted subjective improvements in sleep. Mean saturation value remained unchanged when temazepam was compared with placebo (74.65% v 75.70%, P=0.5437). There were fewer changes in oxygen saturation when participants took temazepam and when measured as decreases >4% below the mean value of saturation each hour (P=0.0036, paired Students t test (two tailed)). Conclusions: Participants taking temazepam at 5300 m showed no significant drop in mean oxygen saturation values during sleep. Both the number and severity of changes in saturation during sleep decreased and the quality of sleep improved. This may be a result of a reduction in the number of awakenings and might lead to greater respiratory stability and fewer episodes of periodic breathing. This has the effect of improving the quality of sleep and reducing the number of periods of desaturation during sleep Key messages Poor sleep at high altitude is common and may be due to a combination of physiological and physical factors Frequent arousals, periodic breathing, and episodes of oxygen desaturation lead to poor sleep and daytime symptoms of drowsiness and reduced performance In this study 10 mg temazepam improved subjective reports of the quality of sleep and reduced episodes of arterial desaturation, with no significant effect on mean oxygen saturation during sleep

Surgery in Global Health Delivery

Surgical conditions account for a significant portion of the global burden of disease and have a substantial impact on public health in low- and middle-income countries. This article reviews the significance of surgical conditions within the context of public health in these settings, and describes selected approaches to global surgery delivery in specific contexts. The discussion includes programs in global trauma care, surgical care in conflict and disaster, and anesthesia and perioperative care. Programs to develop surgical training in Botswana and pediatric surgery through international partnership are also described, with a final review of broader approaches to training for global surgical delivery. In each instance, innovative solutions, as well as lessons learned and reasons for program failure, are highlighted.

Evaluating international global health collaborations: Perspectives from surgery and anesthesia trainees in Uganda

BACKGROUND The number of international academic partnerships and global health programs is expanding rapidly worldwide. Although the benefits of such programs to visiting international partners have been well documented, the perceived impacts on host institutions in resource-limited settings have not been assessed adequately. We sought to describe the perspectives of postgraduate, Ugandan trainees toward international collaborations and to discuss how these perceptions can be used to increase the positive impact of international collaborations for the host institution. METHODS We conducted a descriptive, cross-sectional survey among anesthesia and surgery trainees at Makerere College of Health Sciences (Kampala, Uganda) using a pretested, self-administered questionnaire. Data were summarized as means or medians where applicable; otherwise, descriptive statistical analyses were performed. RESULTS Of 43 eligible trainees, 77% completed the questionnaire. The majority (75%) agreed that visiting groups improve their training, mostly through skills workshops and specialist camps. A substantial portion of trainees reported that international groups had a neutral or negative impact on patient care (40%). Only 15% agreed that research projects conducted by international groups are in priority areas for Uganda. Among those surveyed, 28% reported participation in these projects, but none has published as a coauthor. Nearly one-third of trainees (31%) reported discomfort with the ethics of some clinical decisions made by visiting faculty. CONCLUSION The current perspective from the surgery and anesthesia trainees of Makerere College of Health Sciences demonstrates rich ground for leveraging international collaborations to improve training, primarily through skills workshops, specialist camps, and more visiting faculty involvement. This survey also identified potential challenges in collaborative research and ethical dilemmas that warrant further examination.

Teaching surgical skills using video internet communication in a resource-limited setting.

OBJECTIVE: To study the feasibility and acceptability of using video Internet communication to teach and evaluate surgical skills in a low-resource setting. METHODS: This case-controlled study used video Internet communication for surgical skills teaching and evaluation. We randomized intern physicians rotating in the Obstetrics and Gynecology Department at Mulago Hospital at Makerere University in Kampala, Uganda, to the control arm (usual practice) or intervention arm (three video teaching sessions with University of California, San Francisco faculty). We made preintervention and postintervention videos of all interns tying knots using a small video camera and uploaded the files to a file hosting service that offers cloud storage. A blinded faculty member graded all of the videos. Both groups completed a survey at the end of the study. RESULTS: We randomized 18 interns with complete data for eight in the intervention group and seven in the control group. We found score improvement of 50% or more in six of eight (75%) interns in the intervention group compared with one of seven (14%) in the control group (P=.04). Scores declined in five of the seven (71%) controls but in none in the intervention group. Both intervention and control groups used attendings, colleagues, and the Internet as sources for learning about knot-tying. The control group was less likely to practice knot-tying than the intervention group. The trainees and the instructors felt this method of training was enjoyable and helpful. CONCLUSION: Remote teaching in low-resource settings, where faculty time is limited and access to visiting faculty is sporadic, is feasible, effective, and well-accepted by both learner and teacher. LEVEL OF EVIDENCE: II

Accuracy of the Lifebox pulse oximeter during hypoxia in healthy volunteers

Pulse oximetry is a standard of care during anaesthesia in high‐income countries. However, 70% of operating environments in low‐ and middle‐income countries have no pulse oximeter. The ‘Lifebox’ oximetry project set out to bridge this gap with an inexpensive oximeter meeting CE (European Conformity) and ISO (International Organization for Standardization) standards. To date, there are no performance‐specific accuracy data on this instrument. The aim of this study was to establish whether the Lifebox pulse oximeter provides clinically reliable haemoglobin oxygen saturation (SpO2) readings meeting USA Food and Drug Administration 510(k) standards. Using healthy volunteers, inspired oxygen fraction was adjusted to produce arterial haemoglobin oxygen saturation (SaO2) readings between 71% and 100% measured with a multi‐wavelength oximeter. Lifebox accuracy was expressed using bias (SpO2 − SaO2), precision (SD of the bias) and the root mean square error (Arms). Simultaneous readings of SaO2 and SpO2 in 57 subjects showed a mean (SD) bias of −0.41% (2.28%) and Arms 2.31%. The Lifebox pulse oximeter meets current USA Food and Drug Administration standards for accuracy, thus representing an inexpensive solution for patient monitoring without compromising standards.

Challenges of Anesthesia in Low- and Middle-Income Countries: A Cross-Sectional Survey of Access to Safe Obstetric Anesthesia in East Africa.

BACKGROUND: The United Nations 2015 Millennium Development Goals targeted a 75% reduction in maternal mortality. However, in spite of this goal, the number of maternal deaths per 100,000 live births remains unacceptably high across Sub-Saharan Africa. Because many of these deaths could likely be averted with access to safe surgery, including cesarean delivery, we set out to assess the capacity to provide safe anesthetic care for mothers in the main referral hospitals in East Africa. METHODS: A cross-sectional survey was conducted at 5 main referral hospitals in East Africa: Uganda, Kenya, Tanzania, Rwanda, and Burundi. Using a questionnaire based on the World Federation of the Societies of Anesthesiologists (WFSA) international guidelines for safe anesthesia, we interviewed anesthetists in these hospitals, key informants from the Ministry of Health and National Anesthesia Society of each country (Supplemental Digital Content, http://links.lww.com/AA/B561). RESULTS: Using the WFSA checklist as a guide, none of respondents had all the necessary requirements available to provide safe obstetric anesthesia, and only 7% reported adequate anesthesia staffing. Availability of monitors was limited, and those that were available were often nonfunctional. The paucity of local protocols, and lack of intensive care unit services, also contributed significantly to poor maternal outcomes. For a population of 142.9 million in the East African community, there were only 237 anesthesiologists, with a workforce density of 0.08 in Uganda, 0.39 in Kenya, 0.05 in Tanzania, 0.13 in Rwanda, and 0.02 anesthesiologists in Burundi per 100,000 population in each country. CONCLUSIONS: We identified significant shortages of both the personnel and equipment needed to provide safe anesthetic care for obstetric surgical cases across East Africa. There is a need to increase the number of physician anesthetists, to improve the training of nonphysician anesthesia providers, and to develop management protocols for obstetric patients requiring anesthesia. This will strengthen health systems and improve surgical outcomes in developing countries. More funding is required for training physician anesthetists if developing countries are to reach the targeted specialist workforce density of the Lancet Commission on Global Surgery of 20 surgical, anesthetic, and obstetric physicians per 100,000 population by 2030.