In Response.

Abstract

We read the letter from Coonan et al1 with interest and appreciate the opportunity to make some comments. Coonan et al1 are concerned that authors from low- and middle-income countries (LMICs) are not sufficiently represented in this special edition on Global Anesthesia and Surgery.2 We agree that there is a need “to hear more from the health professionals who provide the essential anesthesia in the least developed countries.” Only 3 of the 15 articles do not have an author from an LMIC, and they include our lead editorial,3 the article from Kassebaum and McQueen,4 and the vision for the future article by Hendel and Absalom.5 All other presentations have authors from LMICs, and they are the lead authors in 4 of them. LMICs represented include Ethiopia, India, Zimbabwe, Thailand, Mongolia, Zambia, Serbia, Venezuela, Honduras, Pakistan, Benin, Tonga, and Uruguay—thus presenting opinions from Asia, Africa, Eastern Europe, the Pacific Islands, and Central and South America. Also included are opinions from surgeons and obstetricians from all income areas, thus giving a wide representation of regions and specialties. The reports on the programs from Mongolia6 and Benin7 clearly illustrate what local anesthesia providers can do when given appropriate long-term support and mentorship. Morris et al8 describe the anesthesia program in Fiji (now a high middle-income country), which is led by Pacific Islanders and has developed with support from many sources. Graduates from Fiji and Benin are now the leaders and teachers throughout their regions, many in low-income and low- to middle-income countries. Surely, this is the ultimate goal? It is certainly what we wished to highlight. We agree with Coonan et al1 that more data are needed on all aspects of anesthesia and surgery in LMICs. However, we recognize how difficult they are to obtain. Evans et al9 note that fact in their article on short subspecialty courses. They present evidence of practice improvement and knowledge translation from Rwanda.10 One might further assume that the propagation of all of these short courses by local anesthesia providers would provide evidence of their value. Primary trauma care, for example, has been taught in >70 countries, has been translated into 14 languages, and has trained tens of thousands of people in Asia, Africa, and Latin America.9 This propagation has been driven predominantly by local health care providers rather than visiting teams. McQueen et al11 previously criticized the World Federation of Societies of Anaesthesiologists (WFSA) Standards for the Safe Practice of Anaesthesia. They reiterate here their theory that the “bare minimum” is all that is necessary. Not everyone supports their opinion.12 One might agree that, for lifesaving surgery in the poorest of environments, the bare minimum might be acceptable, but we doubt anyone would agree that all anesthesia providers should not aspire to more. That is what the standards are about, and while it is recognized that many places in LMICs are “not there yet,” those of us in more fortunate situations should be assisting colleagues to use the standards to advocate for what they require. Often, those most in need are least able to articulate that need and advocate for themselves. The World Health Organization (WHO)–WFSA Standards for the Safe Practice of Anaesthesia have recently been updated and published.13 The involvement of the WHO in the development and approval of these standards speaks volumes for their importance. As countries all over the world develop their National Surgical, Obstetric and Anesthesia Plans in concert with the Lancet Commission recommendations14 and the World Health Assembly motion of 2015,15 it is vital that anesthesia leaders everywhere have a seat at the table and an equal voice in the advocacy. Angela Enright, MB, FRCPCDepartment of AnesthesiaUniversity of British ColumbiaRoyal Jubilee HospitalVictoria, British Columbia, Canada[email protected] Robert McDougall, MBBS, FANZCADepartment of AnesthesiaAnaesthesia and Pain ManagementUniversity of MelbourneThe Royal Children’s HospitalMelbourne, Victoria, Australia