Author: Martin Dünser
Position: MD
Institution: Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck/Austria
E-mail: martin.duenser@i-med.ac.at
Additional Authors: Wolfgang Lederer, MD
Submitted Date: June 16, 2008
Published Date: June 19, 2008
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Dear Sir,
We want to thank and congratulate Drs. Ozgediz and Riviello for addressing a so far neglected topic in global public health (1). The authors conclude that surgical conditions in tropical countries are low valued compared to infectious diseases. We would like to amend their suggestions to improve perioperative patient care in resource-limited areas. Hereby, not only capacity-building measures regarding surgery need to be taken into account, it is of great importance to focus also on perioperative anaesthesia care when trying to reduce perioperative morality. Investment in anaesthesia services is vital to assure safer surgery and obstetric care, particularly in low income countries (2). Comparable to the situation of surgery (1), anaesthesia is a significantly under-resourced specialty in Sub-Saharan Africa (2-4). Prevention of upper airway obstruction, tracheal aspiration and hypoxia as well as adequate perioperative fluid management can dramatically reduce the number of perioperative complications and deaths (2, 5-8). Accordingly, global or local initiatives to assure essential supplies for surgery should also include basic anaesthetic devices such as a source of oxygen (e.g. an oxygen concentrator), a pulseoxymeter, and a simple device to administer volatile anaesthetics (e.g. a draw over vaporizer). Most anaesthetists in Sub-Saharan Africa countries are non-physicians (2-4). Basic training of nurses, medical officers/assistants and physicians in general and particularly regional anaesthetic techniques will rapidly increase the quality and safety of anaesthesia and perioperative care. In addition, more physicians must jointly be attracted to become surgeons or anaesthetists under desirable working conditions. After all, when outlining the complex pathway to reduce death and disability-adjusted life years from surgical conditions in Sub-Saharan Africa further essential points such as injury prevention, adequate prenatal care and basic emergency medical services need to be approached.

References
1. Ozgediz D, Riviello R (2008) The “Other” Neglected Diseases in Global Public Health: Surgical Conditions in Sub-Saharan Africa. PLoS Med. 5: 121.
2. Walker IA, Wilson IH (2008) Anaesthesia in developing countries – a risk for patients. Lancet. 37: 968-969.
3. Jochberger S, Ismailova F, Lederer W, Mayr VD, Luckner G, et al. (2008) Anesthesia and its allied disciplines in the developing world: a nationwide survey of the Republic of Zambia. Anesth Analg. 106: 942-948.
4. Hodges SC, Mijumbi C, Okello M, McCormick BA, Walker IA et al. (2007) Anaesthesia services in developing countries: defining the problems. Anaesthesia. 62: 4-11.
5. Megafu U (1985) Factors influencing maternal survival in ruptured uterus. Int J Gynaecol Obstet. 23: 475-480.
6. Oji A (1986) Intensive care in a developing country: a review of the first 100 cases. Ann R Coll Surg Engl. 68: 122-124.
7. Khan M, Khan FA (2007) Anesthetic deaths in a developing country. Middle East J Anesthesiol 19: 159-172.
8. Mock C, Visser L, Denno D, Maier R (1995) Aggressive fluid resuscitation and broad spectrum antibiotics decrease mortality from typhoid ileal perforation. Trop Doct 25: 115-117.