Comfortably Numb – in praise of Anaesthetists, the unsung heroes of the theatre

In 2017 the World Federation Societies of Anaesthesiologists launched a tool mapping the total number of anaesthesia providers worldwide. A high number of countries reported that there were less than 5 anaesthesia providers per 100,000 people. Of the 37 countries in sub-Saharan Africa which were surveyed, only 5 of them had more than 1 physician anaesthetist per 100,000 people.

In Zambia, there are currently 0.49  physician anaesthetists per 100,000 people, significantly short of the Lancet Commissions target of 20 physician anaesthetists per 100,000 by 2030.  Non-physician anaesthetists (clinical officers trained in anaesthesia, but without training as a doctor first) have been propping up work in the country for years.  Zambia has also started training nurse anaesthetists to increase the number of anaesthesia providers nationally.  Although clinical officers and nurse anaesthetists do an excellent job in difficult circumstances, the need for physician anaesthetists to provide care for the most complex or unwell patients, and to support the non-physician anaesthetists in their role, is great and if Zambia is to reach the target of the Lancet Commission on Global Surgery of 20 surgical, anaesthetic, and obstetric physicians per 100,000 population by 2030, there is urgent need to train more physician anaesthetists.

In 2011, a partnership which, over the years has included the Zambian Ministry of Health, the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the Department of Anaesthesia of Zambia’s University Teaching Hospital, and the Society of Anaesthetists of Zambia (SAZ) have, together with the University of Zambia’s School of Medicine and THET Zambia, set up a training programme aiming to train Zambian physician anaesthetists in Zambia. The Zambia Anaesthesia Development Program (ZADP) has been running since 2012 to support the development of anaesthesia in Zambia. The Program has two main strategies- to train doctors in Zambia to become Physician Anaesthetists using volunteer overseas faculty to deliver the training, and to work with these doctors on quality improvement projects thereby developing anaesthesia and critical care services.

23 Zambian clinicians have now been trained through the programme (with a further 7 completing the training without submitting the dissertation). This has increased the number of anaesthetists in Zambia exponentially (from 22 to 45), but has still missed the initial target of 10 people trained per year by a significant amount. So why aren’t people keen to take on the challenge of this fantastic training?

As skilled as surgeons requiring the same number of years’ specialist training and vital to performing safe surgical procedures, anaesthetists run intensive care units, they offer critical care outreach, acute and chronic pain services, and sedation services for minor procedures. Often seen as simply just an enabler of surgery, anaesthetists are some of the unsung heroes of the medical world. And this is part of the problem- if you are going through the same amount of training as surgeons, if your work is essential for keeping patients alive during surgery and it’s proven that there are better outcomes for patients with an anaesthesia specialist present during operations, why would you want to be ‘unsung’? Obviously this is a pessimistic outlook on why people train to be doctors, but there is no escaping the view that one of the reasons that anaesthetics in Zambia is such a hard sell, is because of the anonymity that it gives to people who deserve to be in the spotlight.

In Zambia, undergraduate medical students only receive 2 weeks of training on anaesthetics. In the UK, it’s not much better- it is well recognised that it is lacking nationally. With this short insight into what a career in anaesthetics could look like, it’s no wonder that not many of them consider it seriously as a pathway. Many people have the view that anaesthesia is a technician or nurse-led speciality, and have no idea of the complexities and intricacies involved. If medical students are not introduced properly to what anaesthetics really involves, it is never going to be a career option that they pursue.

ZAPD has tried to encourage more people to take up training by targeting them where they are already working. Anaesthetists from the Society of Anaesthetists of Zambia have spent time visiting internship sites to try to interest junior doctors in the programme. They have been engaging junior doctors through taster days, training opportunities and other ways to showcase career opportunities available through anaesthesia .  And they have expanded their training programme so that trainees can be trained where they are already working, rather than forcing them to move to Lusaka.

The essential role of anaesthesia in the provision of surgical care, is often not recognised by decision makers, and so consequently given an even lower priority than surgery, which has itself been described as the ‘neglected stepchild of global public health’. ZADP has recently developed a charity called the Global Anaesthesia Development Project to support the work of the organisation in Zambia, and in future other low and middle income countries.  Ethiopia is one of GADPs future areas of work. They are an excellent example of how a single programme can develop into a much wider cause, integrating with existing global efforts such as Lifebox, and the SAFE courses developed by WFSA. If we are to tackle the ever increasing burden of disease and illness, the low profile of anaesthesia and surgery in global health must be raised, and programmes like ZADP should be encouraged and promoted in order to build up a new generation of anaesthetic specialists.