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With the release of the report of the Lancet Commission on Global Surgery1 in 2015, the world’s attention was drawn to the lack of access to safe anesthesia and surgery when needed for 5 billion of the world’s 7 billion people. The focus was on issues in low- and middle-income countries (LMICs) where the need is dire, where safety is often a distant dream, and where patient suffering is great. The Lancet report emphasized that the economic impact of doing nothing will be enormous.1
In this issue of Anesthesia & Analgesia, Orser et al2 remind us that we need to also look closer to home. In their article “Improving Access to Safe Anesthetic Care in Rural and Remote Communities in Affluent Countries,” they delineate issues that face patients who live far from major centers and who require surgical care. About 19% of Canadians3 (6.3 million) and Americans4 (60 million) and 10% of Australians5 (2.6 million) live in rural areas.
Those who live in rural or remote communities have a number of challenges. They tend to
- be poorer than their urban counterparts,
- have more frequent accidents,
- display less healthy behaviors,
- undergo reduced screening for disease, and
- present late with health problems.6
Thus, they have a need for comprehensive primary health care that should be available locally. Indigenous people in Australia, Canada, and the United States are particularly at risk because, in comparison to their non-Indigenous counterparts, they more often live in remote and inaccessible locations. The challenges of improving rural and Indigenous health outcomes are often interlinked.
According to a 2011 Government of Canada website,7 there are 292 remote communities in Canada that are not on the electrical power grid. These areas house >194,000 people, of whom >126,000 are Indigenous. As of January 2015, there were 169 drinking water advisories in 126 First Nation communities.8 It is difficult to be healthy when there is no clean water to drink. Similar concerns relating to the quality of drinking water have been expressed in Australia.9
At the 2015 General Health Assembly, the World Health Organization added surgery and anesthesia to primary health care as an essential component of Universal Health Care coverage.10 The Lancet Commission assesses the burden of surgical disease to be about 28%–32% of the global burden of disease.1 That has grown from the 11% estimated in 2011.11 So, while many LMICs are developing National Surgical Obstetric and Anesthesia Plans (NSOAPs),12 what are high-income countries (HICs) such as the United States, Canada, and Australia doing to address the issues of providing service to those who live in rural and remote communities?
In our opinion, 3 developments since the 1980s have adversely affected surgical services in rural areas:
- decisions of governments to centralize service for financial reasons,
- subspecialization of medical training, and
- research showing that outcomes are better when procedures are performed in centers with large numbers.
Although reasonable at first glance, there have been consequences: loss of generalist surgeons, loss of anesthesia providers, loss of interventional obstetrics, closure of operating rooms, and even smaller hospitals. As a result, there is decreased capacity for trauma management and critical care and increased difficulty in recruitment and retention of all health professionals.13 While the outcomes are better for complex procedures done in high-volume centers, the evidence is much weaker for basic procedures.14 Rural centers in HICs, such as Canada, Australia, or the United States, should be able to provide the Bellwether procedures, as described in the Lancet Commission.1 These include cesarean section, appendectomy, laparotomy, and treatment of an open fracture. They are essentially the same procedures recommended in Disease Control Priorities 3,11 which should be available in a first-level hospital, within 2 hours of a patient’s home.
Orser et al2 describe some of the ways the problem of surgery in rural and remote areas could be addressed, such as family physicians providing enhanced care, developing relationships between the specialist and generalist workforces, in vivo clinical coaching, and telemedicine.2 There is little doubt that these would help, although we must wonder if the networks exist in many of these remote areas to enable the facilitation of the latter 2 services.
In an age of fiscal restraint, governments are struggling to meet the needs of rural patients, especially for transportation if repeat visits are required. Humber and Dickinson15 describe a patient in rural Canada hitchhiking back home after surgery. There are also social and cultural stressors: being overwhelmed by a larger center, the foreign environment, and lack of friend or family support. Communication with the medical staff can be impaired because of language issues, fear, and unfamiliarity. Lack of cultural sensitivity is a frequent complaint.
There are some questions that linger.
- Training family medicine graduates (“general practitioners” in Australia and New Zealand) to have enhanced skills. There are some funded positions in Canada for 1 extra year of training in anesthesia or obstetrics, although there is only 1 program that offers 2 years of surgical training. This would come at the end of 2 years of training in family medicine. In the end, the family doctor will have undergone 4 years of postgraduate training to be a generalist surgeon in a remote area. With 1 further year of training, he or she would be a specialist surgeon. It is hard to see what the attraction would be for a young graduate. Australia offers rural general practitioners (RGPs) a 1-year anesthesia training program, and both a 6-month certificate and a 12-month diploma in obstetrics. The latter specifically trains candidates to achieve the competency to perform cesarean delivery. The Royal Australasian College of Surgeons, in collaboration with the 2 RGP training colleges, has developed a program of training, mentoring, and upskilling RGPs in surgical procedures.
- What is an appropriate volume of cases for a family doctor with enhanced skills to do to maintain competence? What is the effect on recruitment and retention of RGPs, and on their capacity to provide emergency care, when they are restricted in their ability to maintain an appropriate elective caseload?
- For family doctors with enhanced skills, they may have the extra expense of running their family medicine office while they provide the anesthesia service, thus increasing their costs. Add to that the extra on-call burden with minimal remuneration.
- Family doctors with extra skills need to have continuing education in their enhanced area, for example, anesthesia, as well as keeping up with their family medicine continuing professional development. That is both difficult to do and expensive. Locums to provide coverage for them are difficult to get.
- The commitment of governments to provide surgical and anesthesia services in remote areas seems to wax and wane. Funding for training, recruitment, and retention of all health professionals is scarce, and supplying hospitals with the basic resources required to support surgical and anesthesia services (eg, computed tomography [CT] scanners, and ultrasound) is tenuous at best.
In the United States, almost 25% of all physicians are International Medical Graduates (IMGs) and about 50% of these come from LMIC.16 In both Australia and Canada, rural and remote communities that find themselves unable to recruit locally trained specialists often rely on specialist IMGs. It is a sad paradox whereby these countries are providing the workforce for HIC rural health care.
The persisting inequities in rural health service delivery at times seem intractable, although perhaps there is cause for cautious optimism. We are seeing rural and Indigenous health becoming firmly established on the agendas of Colleges and Governments in Australia and Canada, with an associated commonality of purpose, in a manner that was not evident in years gone by. We are witnessing an increasing number of medical graduates from rural and/or Indigenous backgrounds. Pleasingly, in Australia, this cohort is expressing a keen interest in anesthesia training, in parallel with the creation of new rural training opportunities for both specialists and RGPs. Of course, for this to translate into an expanded rural workforce will require the full support of all stakeholders.
Orser et al2 identify the need for professional medical organizations to respond. The Australian and New Zealand College of Anaesthetists (ANZCA), supported by Commonwealth funding, is looking to develop rurally located specialist training schemes. ANZCA’s fellowship surveys17 are exploring the reasons behind the well-documented maldistribution of specialists between urban and rural areas.18 Options to maximize opportunities for cultural competency training for all Fellows are being examined. ANZCA provides logistical and collegial support for the Rural Special Interest Group and is working with the RGP colleges to significantly strengthen training for RGP anesthesia. Importantly, the College needs to consider its role in advocating for improvements in the socioeconomic determinants of rural and Indigenous health.
In Canada, the Royal College of Physicians and Surgeons of Canada (RCPSC) has mandated cultural competency training for all trainees. The RCPSC, the College of Family Physicians of Canada, the Society of Rural Physicians of Canada, and the specialty societies in anesthesia, surgery, and obstetrics are collaborating with universities to come up with solutions to these difficult problems.
The problem of anesthesia and surgery provision in rural and remote communities clearly continues to be hugely challenging. It requires enormous commitment from all levels of government, from the health professions, and from the training programs to initiate and sustain change. First, the social determinants of health such as poverty and disease prevention need to be addressed. Then it must be demonstrated that there is a commitment to, at least, providing the Bellwether procedures locally, and to all of the costs that are involved in doing so. There has to be a strengthening of medical education for practice in rural and remote areas and ongoing support for all health professionals in the community. Finally, there needs to be a commitment to long-term change and that, as we know, is the hardest part.
In his Reflections on the 40th Anniversary of Alma-Ata, Griswold et al19 quoted the Chinese philosopher Laozi: “Go to the people. Live among them. Learn from them. Start with what they know. Build on what they have.” Good advice indeed.
Name: Angela Enright, MB, FRCPC.
Contribution: This author helped write the manuscript.
Conflicts of Interest: A. Enright is a former President of the World Federation of Societies of Anaesthesiologists (WFSA).
Name: Rodney Mitchell, BMBS, FANCZA.
Contribution: This author helped write the manuscript.
Conflicts of Interest: R. Mitchell is the current President of the Australian and New Zealand College of Anaesthetists (ANZCA).
This manuscript was handled by: Jean-Francois Pittet, MD.
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