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Pediatric healthcare – the role for anesthesia and critical care services in the developing world

Readers of this journal will be used to considering reports of innovations in practice leading to excellent outcomes from high quality services. However, the provision of care for children in the poorest countries of the world and the state of anesthesia and critical care services for these children is rarely described. The tragedy of global health inequality is reflected in the lives and deaths of children. An estimated 26 000 children die every day, most of these in the WHO health regions of sub-Saharan Africa or South Asia. In Africa, one in six children does not survive to their 5th birthday, in South Asia one in 12 children will die under 5 years of age. The majority of these child deaths are preventable. Most occur during the neonatal period, an estimated four million of the annual 9.7 million child deaths worldwide, 50% of these within the first 24 h of life. For every newborn that dies, another 20 will suffer from birth injury leading to life-long disability. In older children, the most common causes of death are pneumonia (19%), diarrheal diseases (17%), malaria (8%), measles (4%), injuries (3%) or AIDS (3%), with poor nutrition implicated in up to 50% of all deaths in children under five (1). Newborn and child health are obviously linked to maternal well-being; sub-Saharan Africa has some of the highest rates of maternal mortality worldwide. In September 2000, leaders from over 190 countries met at the United Nations Headquarters in New York and adopted eight Millennium Development Goals (MDGs) to address global inequalities, and set a deadline of 2015 to achieve them. Two of the MDGs relate directly to the health of children – MDG 4 is to reduce under-5 mortality by two-thirds between 1990 and 2015, MDG 5 is to reduce by three quarters the maternal mortality ratio between 1990 and 2015. At the half-way mark to the 2015 deadline, there has been no progress in achieving MDG 4 in 27 countries, mainly in Sub-Saharan Africa, and negligible progress in improving maternal mortality in the developing world. Sub-Saharan Africa and South Asia still account for 86% of the more than 500 000 maternal deaths that occur annually (2). The Countdown to 2015 for maternal, newborn, and child survival was established in 2005 to track progress essential to attain MDG 4 and 5. The 2008 report highlighted the lack of progress in many countries, despite massive increases in funding from donor organizations (3,4). Routine or simple interventions such as immunization or antenatal care have a much higher coverage than those that rely on functional health systems or 24-h availability of clinical care. The group concluded that interventions such as care in childbirth or clinical case management of illnesses in newborn babies and children should be prioritized (3). The relevance of this conclusion to anesthesia and acute care services for mothers and children is immediately obvious, yet rarely considered. Neglect of acute hospital services in many developing countries has had a particularly devastating effect on anesthesia services. Since 2000, various hospitals have reported avoidable anesthesia mortality rates ranging from 1 : 133 to 1 : 482 anesthetics, many of these deaths in fit young patients as a result of airway problems or hypovolemia, many of them mothers undergoing anesthesia for cesarean section (5). Common to all these reports is a lack of medically qualified anesthetists, lack of supervision Correspondence to: Isabeau Walker, Great Ormond Street Hospital NHS Trust, London, UK (email: isabeauwalker@mac.com). Pediatric Anesthesia 2009 19: 1–4 doi:10.1111/j.1460-9592.2008.02866.x