Downloaded from http://journals.lww.com/anesthesia-analgesia by BhDMf5ePHKbH4TTImqenVNlUEzghFiXb4olX/j4P2yUT4G1aWKCbQndips3po238 on 03/19/2020 Copyright © 2020 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. April 2020 • Volume 130 • Number 4 www.anesthesia-analgesia.org 841 DOI: 10.1213/ANE.0000000000004638 E EDITORIAL GLOSSARY AFAT = Anaesthesia Facility Assessment Tool; GP = general practitioner; NPAP = nonphysician anesthesia provider; NSOAP = National Surgical Obstetric and Anesthesia Plan; PIPES = PIPES Surgical Assessment tool - Personnel, Infrastructure, Procedures, Equipment, and Supplies; SAO = Surgeons, Anesthesiologists, and Obstetricians; WFSA = World Federation of Societies of Anaesthesiologists; WHO = World Health Organization ANESTHESIA CARE AND THE RURAL–URBAN DIVIDE Although the world is increasingly rapidly urbaniz- ing, 1 there is a great disparity between countries. Most of the population of sub-Saharan Africa live in rural areas and especially so in the poorest countries. For example, 56.5% of Zambians, 66.2% of Tanzanians, and 83.1% of Malawians live in rural areas. 2 Rural populations, with a huge burden of surgical dis- ease, 3 have particularly poor access to safe, timely, and affordable surgical care. District-level hospitals almost never have specialists in surgery, obstetrics, or anesthesia. During medical school and internship, the general practitioners (GPs) who staff district hospitals have some training in surgical skills; for example, they are expected to be able to perform cesarean deliveries. However, these GPs are not trained in anesthesia. In Tanzania, Malawi, and Zambia, most anesthesia care in rural areas is provided by nonphysician anes- thesia providers (NPAPs). These anesthesia provid- ers either have a nursing background or are clinical offcers/assistant medical offcer anesthetists (a non- physician cadre who has studied for a medical diploma before entry into anesthesia training). However, even these NPAPs are few for the burden of disease, are therefore overworked, become burned out, and often leave anesthesia practice in rural areas. In some dis- trict hospitals, there is no one with formal anesthesia training, and provision of anesthesia is left to the sur- geon (GP) or someone else who is expected to “learn on the job”—a euphemism that may mean being given a syringe of ketamine but few instructions on how to manage the case while the surgeon works. This is symptomatic of how far anesthesia is behind our surgical colleagues, even within the context of chronic underinvestment across surgical disciplines. As East and Southern African countries have devel- oped their health care and medical education systems after independence in the 1960s, postgraduate train- ing programs in surgery and obstetrics tend to have been prioritized. In Tanzania, physician anesthesia training began in 1982, but it has been challenging to recruit physicians to a specialty low in status, and only around 40 anesthesiologists have been trained since then. The frst medical school in Malawi was not built until 1991, and residency training in general surgery began in 2005 4 and in anesthesia only in 2010. To date, there are only 4 Malawian-trained anesthe- siologists. In Zambia, the School of Medicine at the University of Zambia opened in 1966. There has been a surgical residency program since 1986, 5 but there was no training program for anesthesiologists before 2011. 6 The frst anesthesia graduates in 2015 have had the challenge of having to build a profession of anes- thesiology from the day they fnished their residency. Anesthesia Capacity in Rural Zambia, Malawi, and Tanzania: The Anesthesiologist’s Perspective Tuma Kasole-Zulu, MBChB,* Ansbert S. Ndebea, MD,† Singatiya S. Chikumbanje, MBBS,‡ and M. Dylan Bould, MBChB§ See Article, p 845 From the *Department of Anaesthesia and Critical Care, Mansa General Hospital, Mansa, Zambia; †Department of Anaesthesia, Kilimanjaro Christian Medical University College, Kilimanjaro, Moshi, Tanzania; ‡Department of Anaesthesia and Intensive Care, Queen Elizabeth Central Hospital, University of Malawi College of Medicine, Blantyre, Malawi; and §Department of Anesthesiology and Pain Medicine, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Canada. Accepted for publication December 16, 2019. Funding: None. The authors declare no conficts of interest. Reprints will not be available from the authors. Address correspondence to M. Dylan Bould, MBChB, Department of Anes- thesiology and Pain Medicine, Children’s Hospital of Eastern Ontario, 401 Smyth Rd, Ottawa, Ontario, Canada. Address e-mail to dbould@cheo.on.ca. Copyright © 2020 International Anesthesia Research Society