To the Editor,

We appreciate the opportunity to reply to the response of Peters et al.1 to our recent letter in the Journal.2 We are grateful for the opportunity to clarify our position.

There is a significant difference between goals and standards. It is a mistake to conflate the policy ambitions of Disease Control Priorities (Third Edition),3 the Lancet Commission on Global Surgery,4 the World Health Assembly resolution 68.15,5 and the United Nations Sustainable Development Goals,6 with our comments on the recently published World Health Organization-World Federation of Societies of Anaesthesiologists (WHO-WFSA) International Standards for the Practice of Safe Anesthesia.2,7

We believe that there are two lenses through which one may analyze the role of international standards for anesthesia.

On the one hand, there is the important process of defining, promulgating, and supporting the essential requirements for the practice of safe anesthesia through guidelines and standards. In many instances, this first lens reflects the perspective of international institutions whose work it is to support efforts to improve the health service provision for low- and middle-income country (LMIC) populations. These requirements may be both practical and aspirational, and target ministries of health, hospital administrations, and national professional bodies. The recently published WHO-WFSA International Standards seen through this lens are to be applauded and vigorously supported.7

On the other hand, the second lens reflects the realities faced by LMIC anesthesia providers, who have been struggling with the resources available to them to improve the lives of patients long before Global Surgery 2030 was published in 2015.4 The key question is how best to support the development of anesthesia towards the laudable goals of Global Surgery 2030 and the WHO-WFSA International Standards? Unfortunately, the simple enunciation of International Standards in itself does not create a development roadmap. It describes an ideal destination. It does nothing to produce the “staff, stuff, space, and systems”8 needed to meet the goals of Global Surgery 2030.8,9 In the meantime, the lack of funding will have far more impact than any aspirational activities. As stated in our letter “guidelines such as those implied by the WHO-WFSA document are essential, but, on the other hand, practical and evidence-based stepping stones must also be offered to support those who cannot yet reach this ideal. Patient safety is not all or nothing.”2

Our goal is not to deny the important work of the international institutions that influence ministries of health, hospital administrations, and national professional bodies through guidelines, standards, and National Surgical, Obstetric, and Anesthesia Planning (NSOAP), but rather to ensure that the anesthesia providers, who have little or no voice, are able to provide feedback on the current realities of anesthesia in their LMICs.

We look forward to a time when the WFSA-WHO Anesthesia Guidelines will be achieved in every operating room and post-anesthesia care unit around the world. In the meantime, it is our goal that practical, safe anesthesia, based on context relevant training and education for anesthesia service providers, will be increasingly available so that essential surgery may continue to increase towards the additional 143 million surgeries needed a year.4 We do not believe, as suggested by Dr. Gelb, that it is responsible to recommend that “only emergency surgery be provided until all the highly recommended guidelines be met.”9 We suggest instead a bare minimum, with planned scale-up to the highly recommended guidelines, so that a hernia can be repaired before becoming incarcerated, and an elective Cesarean Delivery can be performed before it becomes an emergency, at which point the life of the mother or baby or both are already at risk.10

We acknowledge the inclusive process of an NSOAP and applaud this effort. But we must report that, from the National Anesthesia Society perspective and the comments of participating physician anesthesiologists, the anesthesia perspective is not always heard, even when anesthesiologists engage. There are several current examples of this reality. In Ethiopia, no anesthesiologist was included as an author of the World Journal of Surgery publication explaining the national plan,11 and in Rwanda and Mozambique, anesthesiologists report their recommendations going unmet. Our goal is to offer feedback to the NSOAP’s process so that future efforts can be more inclusive, and therefore successful.

Anesthesia in LMICs faces unique challenges that may not be easily understood or addressed by surgeons alone. We hope that Drs Peters, Meara, Makasa, and Johnson, who are all surgeons, will agree to join in a discussion that will include all anesthesia providers from LMICs.