Month: January 2020

Surgery and anesthesia are essential health services, but they are unavailable in many parts of the world.¹ An estimated one third of the world’s population does not have access to essential surgical resources, and even more people are exposed to unsafe anesthesia practices.¹ Low- and middle-income countries face shortages in human resources, technical resources, education systems and other utilities that prevent them from achieving the same standards of anesthesia care as high-income countries.² When anesthesiology practitioners from high-income countries travel to low-resource settings to provide care, they are often confronted by a lack of resources and different health issues among their patients.³ Anesthesia providers should consider the low anesthetic capacity in low- and middle-income countries, the importance of safe anesthesia and future strategies to approach global anesthesia care.¹

Anesthesia is necessary for the management of a variety of situations, including obstetric surgery,⁴ childbirth,⁵ abdominal surgery,⁶ injuries⁵ and other surgical conditions. However, providers in low-resource settings are unable to give proper anesthesia care to patients due to shortages of personnel, drugs, equipment and training.⁷ For example, a study by Hodges et al. found that in Uganda, only 23 percent, 13 percent and 6 percent of anesthetists had the facilities to deliver safe anesthesia to an adult, to a child and for a Cesarean section, respectively.⁷ Additionally, many educated clinicians in low-income settings emigrate to places with more opportunities for growth and better resources.⁸ As a result, anesthesia providers in low-resource areas have few role models, low wages, inadequate equipment and limited professional development opportunities.^5,8 Overall, an insufficiency of technological supplies, medications and training combined with a small workforce makes anesthesia care low in quality, if existent at all, in low-resource settings.

Yet anesthesia care is highly important to health care and general success of low-income regions.¹ Conservative estimates show that conditions requiring surgery and anesthesia contribute to 11 percent of the global burden of disease, and poor anesthetic care could result in further morbidity or mortality.⁹ For example, the inability to provide safe anesthesia for women in childbirth, whether for Cesarean section or vaginal delivery, contributes to high fetal and maternal mortality rates in low-resource settings.¹⁰ Anesthetic shortages also contribute to disparities in global mortality rates from injuries, as 90 percent of deaths from injuries occur in low- or middle-income countries.¹¹ The Global Burden of Disease Study estimates that by 2030, injuries will be the fifth leading cause of death in low- and middle-income countries, ahead of HIV, tuberculosis and malaria.¹² This is especially concerning given the role anesthesia and surgery play in preventing injury-related deaths. Evidently, anesthesia is crucial to preventing issues such as maternal, fetal and injury-related morbidity and mortality, all of which are common in low-resource regions.¹

Anesthesiology professionals and other health providers can work towards better anesthesia care in low-resource settings. Walker et al. suggest that nurses or clinical officers be provided with effective anesthesia training programs in settings without anesthesiologists.⁸ Hodges et al. encourage local structural changes, such as improvements in local management, finances and logistics.⁷ In their review, Bharati et al. mention that use of local or epidural anesthetics may lower risk of mortality in cases where resuscitation equipment, vital signs monitors and mechanical ventilators are unavailable.² The authors also make a variety of suggestions for enhancing anesthesia provision in low-resource settings, including continuous education for nurse anesthetists, simulation training for medical students, adequate resuscitation equipment, changes in prescription practices and development of transportation infrastructure.² However, these improvements all require contributions by high-income countries and global organizations.² Education and local infrastructure changes may be helpful in low-resource settings, but these advances—along with technological development, proper equipment and improved transportation—may be difficult to achieve without a global effort.

Anesthesia and surgery are crucial to maintaining a healthy population. However, safe anesthesia care is sorely lacking in low-resource settings. A lack of supplies, technology, infrastructure and health professionals makes anesthesiology extremely difficult in low-resource regions. This can contribute to obstetric, injury-related and other surgical complications and mortality. Global health policymakers should shift focus and funding to anesthesia provision in low-resource regions to work toward a healthy global population.¹

1.         Li V, Neuen BL. Access to safe anesthesia: A global perspective. The Journal of Global Health. April 1, 2014.

2.         Bharati SJ, Chowdhury T, Gupta N, Schaller B, Cappellani RB, Maguire D. Anaesthesia in underdeveloped world: Present scenario and future challenges. Nigerian Medical Journal. 2014;55(1):1–8.

3.         University of Oxford Nuffield Department of Clinical Neurosciences. Anaesthesia in Developing Countries. Continuing Professional Development 2020; https://www.ndcn.ox.ac.uk/study-with-us/continuing-professional-development/anaesthesia-in-developing-countries.

4.         Grady K. Building capacity for anaesthesia in low resource settings. BJOG: An International Journal of Obstetrics & Gynaecology. 2009;116(s1):15–17.

5.         Cherian M, Choo S, Wilson I, et al. Building and retaining the neglected anaesthesia health workforce: Is it crucial for health systems strengthening through primary health care? Bulletin of the World Health Organization. May 10, 2010;88:637–639.

6.         Khan FA, Merry AF. Improving Anesthesia Safety in Low-Resource Settings. Anesthesia & Analgesia. 2018;126(4):1312–1320.

7.         Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA, Wilson IH. Anaesthesia services in developing countries: Defining the problems. Anaesthesia. 2007;62(1):4–11.

8.         Walker I, Wilson I, Bogod D. Anaesthesia in Developing Countries. Anaesthesia. 2007;62(s1):2–3.

9.         Ozgediz D, Riviello R. The “other” neglected diseases in global public health: Surgical conditions in sub-Saharan Africa. PLoS Medicine. 2008;5(6):e121.

10.       Dyer RA, Reed AR, James MF. Obstetric anaesthesia in low-resource settings. Best Practice & Research Clinical Obstetrics & Gynaecology. 2010;24(3):401–412.

11.       Bae JY, Groen RS, Kushner AL. Surgery as a public health intervention: Common misconceptions versus the truth. Bulletin of the World Health Organization. 2011;89(6):394.

12.       Lozano R, Naghavi M, Foreman K, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet (London, England). 2012;380(9859):2095–2128.

A diverse workforce is more productive and more representative of the American population.¹ Factors such as race, ethnicity, gender, sexual orientation and religion are frequently considered aspects of diversity, while disability is largely ignored.² Indeed, only 15 percent of top-ranked companies include disability in their definitions of diversity.³ Lack of awareness of the various forms of disability can contribute to conflict and mistrust between employees.⁴ It is unlawful to discriminate against an employee for having a disability,⁵ yet employees with disabilities often face prejudice.⁶ Though the literature on physician disability is limited, health professionals of all types—ranging from clinical psychologists⁷ to nurses⁸—may face disability throughout their lives.⁹ While some guidelines exist surrounding disability-related recruitment and retention among medical students,¹⁰ health professionals may also develop a disability later in life.⁹ In order to reduce discrimination against and provide adequate resources for practitioners with disabilities, anesthesia providers should become familiar with definitions of disability, stigma associated with various conditions and disability in anesthesiology in particular.

According to the Centers for Disease Control and Prevention (CDC), a disability is any condition of the body or mind that makes it more difficult for a person to do certain activities and interact with the world.¹¹ A disability is marked by impairment, such as loss of a limb, blindness or memory loss; activity limitation, such as difficulty reading, hearing, walking or problem solving; and participation restrictions, such as working, engaging in social and recreational activities and obtaining health care services.¹² Specifically, work-related disabilities may result in employment problems because the individual is unable to perform a work role in a manner that is considered “normal.”¹³ A health care professional with a disability is one who is unable to practice medicine or nursing with reasonable skill and safety because of a physical or psychiatric condition.¹³ These vague, subjective definitions lead to a spectrum of interpretations and implementations, often causing stigma against workers with disabilities.⁸ Indeed, one study found that prejudice surrounding certain types of disabilities—such as AIDS, cerebral palsy and stroke—contributed to lower acceptance of the worker.⁶ The complexity of disability in client-facing roles, including the health professions, can have profound personal, professional and societal ramifications.¹³

Disability in anesthesia providers can manifest in a number of ways, and can arise from before medical school to later in life.⁹ For example, disability in anesthesiology includes a practitioner who has suffered an injury or illness and wants to return to practice; a provider with an established impairment who is seeking support or hoping to receive disability insurance benefits; and colleagues who are questioning whether an anesthesia provider with a particular limitation should be allowed to continue practicing.⁹ These issues almost always subjective and ethically challenging, and they are made more complex by the fact that a condition may be disabling in one context, but merely inconvenient in another.¹³ A case study by Fitzsimons et al. found that cognitive disabilities, such as attention deficit/hyperactivity disorder (ADHD), may go undiagnosed among anesthesiology trainees and contribute to the trainee’s struggles throughout residency.¹⁴ Meanwhile, a review by Katz shows that substance use disorder is one of the most common disabilities among resident and attending anesthesiologists.¹⁵ Other disabilities include physical issues, major psychiatric disorders like clinical depression, burnout and age-related dementia.¹⁵ Management of these disabilities among anesthesia providers can be complicated, given prejudices and potential impairment attached to the conditions.¹⁵

Though some degree of impairment will occur in one-third of anesthesiologists during their careers, there are few studies on the role of stigma and work difficulties for anesthesia providers with disabilities.¹⁵ Some general approaches to workplace disability can include diversity management services,⁴ improved definitions of disability in anesthesiology⁸ and individualized programs for anesthesiology trainees or attendings who may require special accommodations.¹⁴ Anesthesia professionals should embrace the diversity that providers with disabilities bring to the workforce⁴ while simultaneously preserving their mission to “do no harm” to patients.⁸

1.         Selden SC, Selden F. Rethinking Diversity in Public Organizations for the 21st Century: Moving toward a Multicultural Model. Administration & Society. 2001;33(3):303–329.

2.         Diversity includes Disability. Accessibility Information 2019; https://accessibility.cornell.edu/diversity-includes-disability/.

3.         Ball P, Monaco G, Schmeling J, Schartz H, Blanck P. Disability as diversity in Fortune 100 companies. Behavioral Sciences & the Law. 2005;23(1):97–121.

4.         Muyia Nafukho F, Roessler RT, Kacirek K. Disability as a Diversity Factor: Implications for Human Resource Practices. Advances in Developing Human Resources. 2010;12(4):395–406.

5.         The ADA: Your Employment Rights as an Individual With a Disability. Washington, D.C.: U.S. Equal Employment Opportunity Commission; 2008.

6.         McLaughlin ME, Bell MP, Stringer DY. Stigma and Acceptance of Persons With Disabilities: Understudied Aspects of Workforce Diversity. Group & Organization Management. 2004;29(3):302–333.

7.         Olkin R. Could you hold the door for me? Including disability in diversity. Cultural Diversity and Ethnic Minority Psychology. 2002;8(2):130–137.

8.         Sin CH, Fong J. ‘Do no harm’? Professional regulation of disabled nursing students and nurses in Great Britain. Journal of Advanced Nursing. 2008;62(6):642–652.

9.         Dangler LA, del Carmen Forrest M. A Diverse Perioperative Physician Workforce Includes Those With Disabilities. ASA Newsletter. 2019;83(6):20–22.

10.       Meeks LM, Jain NR, Moreland C, Taylor N, Brookman JC, Fitzsimons M. Realizing a Diverse and Inclusive Workforce: Equal Access for Residents With Disabilities. Journal of Graduate Medical Education. 2019;11(5):498–503.

11.       National Center on Birth Defects and Developmental Disabilities. Disability and Health Overview. September 4, 2019; https://www.cdc.gov/ncbddd/disabilityandhealth/disability.html.

12.       International Classification of Functioning, Disability and Health (ICF). Classifications March 2, 2018; https://www.who.int/classifications/icf/en/.

13.       Katz JD. The Disabled Anesthesiologist. ASA Newsletter. 2007;71(5):17-21.

14.       Fitzsimons MG, Brookman JC, Arnholz SH, Baker K. Attention-Deficit/Hyperactivity Disorder and Successful Completion of Anesthesia Residency: A Case Report. Academic Medicine. 2016;91(2):210–214.

15.       Katz JD. The impaired and/or disabled anesthesiologist. Current Opinion in Anaesthesiology. 2017;30(2):217–222.