SAWW – Delivering anaesthesia to the world’s poorest people
Carol Newman and Roger Eltringham discuss the work of the charity Safe Anaesthesia Worldwide
Anaesthesia in low-income countries
Attempts to introduce the latest sophisticated anaesthesia equipment to rural hospitals in poor countries have frequently been spectacular failures. The equipment, often purchased by governments and aid agencies at enormous cost, is discovered on arrival to be totally unsuitable as it cannot function in the prevailing hostile conditions. It then remains – unused and unusable – in the graveyards of equipment to be found in the storerooms of hospitals in the world’s poorest countries.
The essential problem is that equipment designed for use in wealthy countries is, despite its great expense, unable to overcome the additional problems encountered in hospitals in poor countries. These hospitals frequently lack oxygen and electricity, without which sophisticated machines are unable to function. Furthermore, the highly skilled engineers needed for servicing and maintaining this complex equipment are seldom available.
The Lancet Commission on Global Surgery estimated that five billion people lack access to safe anaesthesia and surgery, predominantly in poor countries. As a result there are around 16.9 million unnecessary deaths and countless disabilities each year. This figure is four times higher than the number of people dying annually from malaria, HIV/AIDS and tuberculosis combined. The lack of trained anaesthetists and suitable anaesthesia equipment in low-income countries plays a large part in making these statistics so shockingly high.
It was this scenario which prompted the formation of the charity Safe Anaesthesia Worldwide in 2011.
Relieving suffering and saving lives
Safe Anaesthesia Worldwide (SAWW) works to overcome these problems in the following ways:
- by supplying suitable equipment that is specifically designed to function in difficult environments;
- by delivering education to medical and technical staff in poor countries to safely deliver anaesthesia and keep the anaesthetic equipment in good working order; and
- by encouraging research into new ways to overcome local problems to enable the safe delivery of anaesthesia in poor countries.
Equipment designed for use in wealthy countries is often unsuitable for use in low-resourced hospitals in poor countries. Compressed gases are often only available in expensive cylinders that run out and power cuts are frequent. To be successful in such situations, an anaesthetic machine must be able to continue functioning if there is an interruption in the supply of oxygen or electricity (or both simultaneously) and must be simple enough to be maintained and serviced locally without the need for highly trained electronic engineers. It must be safe, effective and inexpensive to run. The following are examples of suitable equipment supplied by SAWW.
Basic anaesthetic machine
A basic anaesthetic machine suitable for draw over and continuous flow anaesthesia. The Glostavent® anaesthesia system has three essential components: an oxygen concentrator to enable oxygen to be produced locally from room air; a draw over breathing system which will function in the absence of compressed gases; and a mechanical lung ventilator which is not dependent on electricity. These unique anaesthetic machines are in use in some of the most hostile regions of the world and SAWW is presently fund raising to supply two machines to Somaliland.
Portable anaesthetic machine
A portable anaesthetic machine enables general anaesthesia to be administered in emergency situations when there are no local facilities whatsoever. The lightweight anaesthetic machine can be carried to the patient in a small case. SAWW has sent these machines in response to urgent appeals for help from doctors working in humanitarian situations, such as Syria and Nepal following the recent earthquake, as well as to various rural hospitals in remote areas of South Sudan, Tanzania and Zambia, where anaesthesia would not otherwise be available.
Sevoflurane analgesic inhaler
A Sevoflurane analgesic inhaler can provide inhalational analgesia and oxygen supplementation, for example for mothers in labour or accident victims requiring transport. SAWW is currently involved in trials of this inhaler with the University of Malaysia.
Continuous positive airway pressure (CPAP) device
A low-cost, oxygen concentrator-driven continuous positive airway pressure (CPAP) device. Pulmonary atelectasis is a potentially fatal condition, commonly seen in infants and young children, caused by collapse of alveoli in the lungs. It can be successfully treated by the application of an adjustable mixture of oxygen and air under variable pressure which is applied to the upper airway via an airtight seal. Treatment may be required continuously for periods ranging from a few hours to a few weeks. The high volumes of air and oxygen required may make the delivery of sufficient cylinders too expensive and logistically impossible in many low-income and low-resource locations. The CPAP device utilises an oxygen concentrator to deliver the desired mixture of gases at a fraction of the cost of cylinders and has made this treatment widely available. SAWW have supplied a number of these lifesaving machines to paediatric departments in Gambia, Ghana and Tanzania.
This is a simple item of essential safety equipment that provides continuous monitoring of oxygenation.
A small gas-driven ventilator can provide long-term lung ventilation at minimal cost for patients unable to breathe spontaneously.
There is a drastic shortage of qualified anaesthetists and a lack of training opportunities throughout the developing world. SAWW recognises the importance of supporting anaesthetists, who often work alone in remote locations, by providing training and educational materials in the following ways.
Care of equipment
Anaesthetists receiving equipment from SAWW are trained in its use, care and basic maintenance and are shown how to avoid extravagance and waste of resources. Equipment is only recommended by SAWW if the manufacturers provide a satisfactory after-sales service so that users do not feel abandoned if they require advice or assistance.
Each year the charity supports educational courses, both in the UK and overseas, in the theory and practice of anaesthesia, and in the care and maintenance of equipment. This year SAWW’s efforts focused on an equipment-training workshop and lectures in Myanmar, a country that under military rule received little input from the outside world until recently. SAWW has also participated in successful anaesthesia training courses held in Mozambique and Ghana. Textbooks and teaching aids have been provided on training courses and to hospitals and departments as requested.
Thanks to the help of anaesthesia and engineering professionals, SAWW has been able to provide training to hospital staff in Indonesia, Gambia, Ghana, Liberia, Myanmar, Malaysia and Tanzania.
The charity has an active and successful research programme which includes improving equipment specifically designed for use in difficult environments. Several items are already in use and have been widely acclaimed.
In 2012 the Royal Society of Medicine selected the mobile anaesthetic machine (DPA 01) as Innovation of the Year. We also contributed to the research teams that were joint recipients of the Association of Anaesthetists Innovation in Anaesthesia, Critical Care and Pain awards in each of the last three years. The respective innovations were a mobile capnograph in 2013, the CPAP device in 2014 and the Helix paediatric ventilator in 2015. We are currently conducting a trial of the sevoflurane analgesia inhaler in co-operation with the University of Kuala Lumpur in Malaysia. This has been entered for the 2016 competition.
The charity is based in the village of Marden in Kent where most of the trustees live. This enables administration costs to be reduced to the barest minimum and also facilitates rapid decision-making and early response to urgent requests for help. For example, we were able to quickly despatch a portable anaesthetic machine to Syria to enable emergency surgery to be performed in safe houses when the local hospital had been destroyed by terrorists. This arrangement proved so successful that further machines were rapidly requested and supplied by other charities. On another occasion we were able to deliver an anaesthetic machine to a hospital near Kathmandu within days of the recent earthquake.
SAWW regularly gives presentations to such organisations as Rotary, rugby clubs, churches, schools and mothers’ unions. Schools have been particularly supportive and several have raised sufficient funds to purchase portable anaesthetic machines for use in emergency situations. SAWW has also provided schools and colleges with career advice, interview technique and lectures on anaesthesia and resuscitation. This has stimulated many ingenious fundraising activities that have enabled work of the charity to continue and expand.
Fundraising is an essential part of every charity and SAWW could not function without the help of volunteers who contribute to a wide range of fundraising activities. Fundraising is enjoyable and immensely satisfying and anyone wishing to help can visit the SAWW website for practical advice. We pride ourselves on spending less than one per cent of income on overheads, so fundraisers and donors can be assured that their money goes directly to help those in great need.
Carol Newman is secretary and Roger Eltringham is medical director of Safe Anaesthesia Worldwide.
For further information, visit www.safe4all.org.uk
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