Anaesthesia in Developing Countries: My Experience - Sarah Rae

SAFE AFRICADuring early December I was lucky enough to visit the magical country of Ethiopia. Since deciding on my career as a doctor, long before I knew I wanted to be an anaesthetist, I knew I wanted to work in developing countries. This is a dream come true for me, having always strived to some-how incorporate this dream with my career choice, but never knowing how to proceed. It has always been a scary prospect, albeit an exciting one. I decided to take the bull by the horns after listening to a talk at the SSA meeting in April 2017. The chap, I forget his name, described his fellowship in Ethiopia. He had nothing but gratitude and attributed the organisation of the fellowship to a certain Dr. Jolene Moore, who by our good fortune, works for The Department of Anaesthesia in Aberdeen. Why had I not thought of contacting her before?  I was blown away by the possibilities; I could do something like this!

Not long after the meeting I contacted Jolene, excited by the prospect of being able to progress with my lifelong dream of working in developing countries. She was receptive and more than willing to facilitate. We discussed several opportunities ranging from teaching on anaesthetic courses such as SAFE and LIFEBOX to doing a fellowship or even a higher unit of training in “anaesthesia for developing countries”. After learning some of Jolene’s background and contacts relating to her work in Ethiopia and worldwide, I was nothing but impressed. Jolene contacted me with possible dates for upcoming training opportunities in Ethiopia. WFSA were looking for international trainers to teach on their SAFE obstetric course in the Tigray region of Northern Ethiopia. Our esteemed South African colleague, Joanna Thirsk, had also contacted Jolene with similar ideas and was called in to help with the course as well.

To give you some background, WFSA (World Federation of Societies of Anaesthesiologists) is a network of global anaesthesia societies which facilitates learning and promotes safer standards of patient care throughout the world. SAFE (Safer Anaesthesia from Education) was launched in 2010 by AAGBI in collaboration with WFSA and other partners. The aim of SAFE is to bring practitioners of anaesthesia (who may or may not be doctors) to a level of practice where they can deliver safe and competent anaesthesia. The SAFE approach combines UK trainers with local instructors who are provided with a training-of-the-trainer course whereby they become the in country SAFE faculty of the future. SAFE 3-day courses have so far focused on Obstetric and Paediatric anaesthesia in over 20 countries with evidence of excellent results.

Anaesthesia is a young specialty in Ethiopia. Before 1976 almost all anaesthesia was provided by foreign anaesthetists. In 1974 the WHO in association with the MOH started a school of anaesthesia in Addis Ababa, the first of its kind in Ethiopia. However, despite significant advances in the provision of safe anaesthesia in high-income countries, anaesthesia-related and perioperative mortality in low-resource settings such as Ethiopia remains high, exacerbated by a critical shortage of anaesthesia providers. It is estimated that in Ethiopia there are currently only around 50 anaesthesiologists (medical specialists with 9+ years of university training), and around 750 anaesthetists (3-4 years of university training or nurses trained for 1 year). This small number - to serve a country of approximately almost 100 million people. Therefore, not only is the ratio of anaesthetic practitioners to population in Ethiopia among the lowest in the world, their education and supervision are often under-resourced, and their work environments can be challenging. Junior practitioners are frequently out-sourced to district hospitals where they are the sole provider for anaesthesia, therefore effectively on-call 24/7 with minimal opportunity for help or support. Unsurprisingly, anaesthetic practitioners migrate back to the larger city hospitals where their prospects of better pay and work-life balance are increased, compounding the problem of the most poorly resourced district hospitals even further.

So, in early December, off we went to Mekelle in Northern Ethiopia with suitcases full of books and equipment worth thousands of pounds. The SAFE Obstetric course was run almost entirely by Jolene and a local anaesthetist called Hentom. We were to be part of the faculty for the Trainer of Trainer Course and then the 3-day SAFE course thereafter. The aim of these courses is to train local trainers to train their local practitioners using novel teaching methods and equipment. The SAFE approach uses a combination of lectures (which are kept to a minimum) and simulation and discussion-based teaching. I say novel, this is not novel to ourselves, however the teaching methods in Ethiopia still tend to be very traditional with mostly lecture-based teaching. As with any organisation, there is a highly political component to the background and organisation of the course. Jolene had worked tirelessly with the Ministry of Health, Association of Anaesthetists and Society of Anaesthesiologists in combination with SAFE and WFSA with the aim to train as many trainers as possible and to reach as many local anaesthetic practitioners as possible in as many hospitals as possible so that Ethiopia can be “self-sufficient” in the future.

The Ethiopian people tended to be a conservative, humble and shy people; the first day of the SAFE Obstetric course was spent using many of our teaching skills attempting to break down these barriers, making the sessions more of an interactive experience. Over the course, the participants became more engaged as they interacted in each session more and more. By the end of the course, most participants were freely answering questions and describing their own experiences, which gave us, as the trainers, an immense feeling of satisfaction. Some participants travelled hundreds of miles to attend the course, sometimes with their breast-feeding infants in tow. The “local” trainers came from all over Ethiopia in order for them to carry on the SAFE courses in their own institutions. The course covers a lot of material which is undertaken in English. Despite anaesthetic teaching in Ethiopia being taught in English, the language barrier at times proved challenging, therefore the local trainers were invaluable in this setting. The days were long for the faculty, not only were we teaching all day but we had to organise the room, lectures and equipment before and after each teaching day and evenings were spent learning the material for the following day. However, despite the long days we still found time to attend the local Ethiopian “cultural club” which was an awesome array of local music, dance, food and culture. Of course, being the whitest person in the room has its disadvantages in this setting where I was dragged up to partake in local dancing by the entertainers. Unbeknown to myself, several of my friendly colleagues filmed this, much to the hilarity of the participants the following day. I still haven’t lived that one down, with several of the girls giving me tips on how to improve my dance technique.

So how can I summarise my first experience of anaesthesia in a developing country? Enlightening, enticing, magical. A world where you can step back in time by 7 years and immerse yourself in a place with its entirely unique food, fauna, language and music. And of course, the immense feeling of fulfilment that you get from the feeling of making a positive impact. My first experience will certainly not be my last and am looking forward to my next adventure in this beautiful country with its beautiful people.

Ethiopia 2017