The glaring differences in health care budgets between high-income countries (HICs) and low-/middle-income countries (LMICs) fuel an ever increasing urge to assist those less fortunate. Countless medical organizations perform service or teaching work in LMICs, and a particularly notable metric is the booming demand for global health experiences that is expressed by medical students and residents, including those in our specialty (Dr. Faye M. Evans, Boston Children’s Hospital, Boston, MA, personal communication). Although personnel shortages and inadequate training may be the main limitations to improving health care in LMICs,1 often what strikes the visiting anesthesiologist more is the problematic infrastructure: lack of basic monitoring equipment, extremely limited drug selection, virtually no airway management devices, antiquated anesthesia machines (or anesthesia delivery systems even barely recognizable as such), and broken equipment sitting in the hallways. It is understandable therefore that, once back home, the question comes up whether it might be possible to transfer some of our wealth in equipment and drugs to the people who are in such need. And this puts one right in the center of the complex issues surrounding the use of HIC materials in LMICs.
In this issue of Anesthesia & Analgesia, Joshi and Onajin-Obembe2 describe an unusual but particularly troubling issue in this area: the request by China that ketamine be made a schedule I drug to limit its use in the country as a recreational drug. This would essentially block anesthesia providers in nongovernment institutions from using the drug. Considering the remarkable safety profile of ketamine and its resultant extensive use as an anesthetic in LMICs, this could be potentially disastrous for anesthesia services in those countries. This issue has been discussed recently in the Lancet.3
But as excessive and problematic as it is, this is truly just one example of the uneasy relationship between HICs and LMICs with respect to materials transfers. A highly ambivalent mindset holds sway here. On one hand, many people feel strongly that anesthesiologists in LMICs should, as quickly as feasible, be brought to the standards of the HIC world. It’s the “what’s good for the goose is good for the gander” approach. For example, there is much interest to introduce ultrasound for diagnostic purposes and for regional nerve blockade.4 The ketamine controversy falls in this category: if HICs can do without the drug, then it also should no longer be used in LMICs. Conversely, many people similarly feel strongly that, because things are so bad “out there,” LMICs would be happy with whatever is no longer usable here. What’s no longer good for the goose may still be of benefit to the gander. Both viewpoints (which at times are held simultaneously with respect to different materials) are frankly rather paternalistic and can lead to a number of significant errors. Let’s review some examples.
- 1. Medications: Many of the drugs donated to LMICs are of little to no use for them. This is typically not an issue in anesthesiology, but on a global scale, the problem is significant. Pharmaceutical companies may donate drugs just to obtain tax breaks, and volunteer organizations often have limited understanding of what is needed in a remote country. The situation during the refugee crisis in Albania in 1999 is a typical example. As described by Snell: “about 50% of the donated drugs were inappropriate or useless and would have to be destroyed. Sixty-five percent of drugs were due to expire within 1 year, and 32% were identified only by brand-names that were unfamiliar to Albanian health professionals. None of the short shelf-life donations was requested, and aid workers reported that they could not be distributed and used before the expiry date.”5
- The issue of drug expiration is very relevant to anesthesiology. For a long time, it was considered appropriate to donate expired but unopened medications to LMICs. The rationale was that drugs don’t go bad right on the expiration date, and even if some potency were lost, “it’s better than nothing.” In 1999, the World Health Organization published guidelines for drug donations, which explicitly state that donated drugs must have a shelf life of at least 1 year after arrival in the recipient country.6 This is based on the simple principle that there should be no double standards in quality: if a drug is unacceptable in the donor country, it is unacceptable in the recipient country.5 Therefore, a useful mental exercise is to reverse the situation: if someone were to bring drugs from a LMIC into your clinical practice, what would you demand as to quality? Well, LMICs demand the same. Yet it seems unlikely that these principles are adhered to for all drugs brought on medical missions.
- 2. Major equipment: The view of old and broken anesthesia equipment is a not infrequent impetus to start looking back home for devices that could be donated or for asking companies to donate new equipment to a LMIC. But 2 things are often forgotten. First, what to many looks like old and inadequate hardware is often specifically designed for the austere environment where it is used. Take, for example, the anesthesia delivery system shown in Figure 1. This may be barely recognizable to a HIC anesthesiologist but in fact is a volatile anesthesia delivery system able to function in an operating room without compressed gases or electricity. Our HIC Boyle’s type anesthesia machines cannot. The high internal resistance of the plenum type of vaporizer requires compressed gas to drive the fresh gas flow, and both the electronic and mechanical components require electricity. In case of electrical failure, the system is temporarily supported by a battery; in case of compressed gas failure, only the back-up tank on the machine allows mechanical ventilation. The system in Figure 1 combines a low-resistance, “draw-over” vaporizer with a manual ventilator. It is the optimal system in an environment where compressed gases are unavailable (transport of tanks is expensive and often erratic) and electrical supply is tenuous and may include voltage swings that our systems are not designed for. Introducing a modern anesthesia delivery system into such an environment is not only poorly considered but also can directly threaten patient safety.
- Several systems have been developed for austere environments and introduce modern conveniences and safety features while retaining the basic features of the draw-over system (e.g., the Glostavent by Diamedica7 and the Universal Anesthesia Machine by Gradian Health8). These are the appropriate replacements, if a replacement is needed in the first place.
- The second problem associated with equipment donations is maintenance and spare parts, both of which are typically unavailable. Hence, even a minor malfunction can put a major piece of equipment out of order, often for long or forever, and that is the cause for the broken equipment in the hallways in LIMC hospitals. The draw-over device in Figure 1 is almost impossible to break. The anesthesia systems specifically built for austere environments similarly have been designed with maintenance issues in mind. But we tend to function in an environment where a clinical engineer can be present within minutes or hours, and our equipment reflects that.
- 3. Disposables: From complex anesthesia delivery systems to kits for regional nerve blocks, our equipment is increasingly dependent on disposable components. Think of membranes for oxygen analyzers in anesthesia machines, water traps for CO2 analyzers in monitors, sterile sleeves for ultrasound probes, stimulating needles, disposable SaO2 probes … These disposables are typically not or intermittently available in LMICs. Therefore, the moment they run out, the system can no longer be used. Worse, the providers may be sorely tempted to reuse disposables between patients, even if not designed for such use. Any donation of material that does not put into place a dependable supply of disposables is likely to be a failure. Ultrasound systems for regional anesthesia, by eliminating the need for stimulating needles, may therefore be a very significant advance (if a system for maintenance and repair is put in place, and a supply of sleeves can be assured…).
China’s problematic proposal requesting that ketamine be listed on schedule I is only an excessive example of what still happens on almost a daily basis: the needs of LMICs are not adequately considered. China’s request received significant pushback, and the United Nations Commission on Narcotic Drugs eventually decided not to place ketamine on any schedule “based upon the involvement of many ministries of health”2 and other groups. For the other issues I discussed, the solution is the same: we need to listen to the providers and governments in LMICs. It’s not for the goose to decide what is good for the gander.
Name: Marcel E. Durieux, MD, PhD.
Contribution: This author wrote the paper.
Attestation: Marcel E. Durieux approved the final manuscript.
This manuscript was handled by: Hugo Van Aken, PhD, FRCA, FANZCA.
1. Durieux ME. But what if there are no teachers …? Anesthesiology. 2014;120:15–7
2. Joshi GP, Onajin-Obembe B. The role of ketamine in low- and middle-income countries: what would happen if ketamine becomes a scheduled drug? Anesth Analg. 2016;122:908–10
3. Nickerson JW, Attaran A. The commission on narcotic drugs’ attempt to restrict ketamine. Lancet. 2015;385:e19
4. Ardon AE, Twagirumugabe TRoth R, Frost EAM, Gevirtz C, Atcheson CLH. A regional anesthesia service in a resource-limited international setting: Rwanda. In: The Role of Anesthesiology in Global Health. 20151st ed New York Springer:257–64
5. Snell B. Inappropriate drug donations: the need for reforms. Lancet. 2001;358:578–80
6. World Health Organization. Guidelines for Drug Donation. 1999 Geneva World Health Organization
9. Dobson MB Anaesthesia at the District Hospital. 20002nd ed Geneva World Health Organization