Elizabeth Drum

Elizabeth Drum Interview: 

David: You started a new position a little while ago, is that correct?  

Elizabeth: I have a couple different responsibilities.  I became chair of a committee within the American Society of Anesthesiologists.  They have a committee, the Global Humanitarian Outreach, within the American Society of Anesthesiologists  that was originally envisioned as a way to send US anesthesiologists to other countries to help in educational efforts around anesthesiology.  Over time some of those programs grew/changed/morphed.  Eventually that committee developed into the GHO.  I have been on that committee for years and just became the chair.  

There are a number of things that committee does within the ASA.  We support two programs, one is in Rwanda, one is in Guyana.  The goal is to help with anesthesiology efforts in those countries.  

The program in Rwanda was originally a partnership with the Canadian Anesthesiologists’ Society.  So, the two societies went and taught residents in Rwanda.  Over time the Rwandan Anesthesia Society has grown stronger, more robust, there’s now graduates who are leading the teaching efforts.  The ASA and CAS efforts have changed more into supporting the faculty, helping them learn to become educators and leaders, and not so much providing hands on teaching, but supporting the leaders in that country.  

It’s an amazing testament to the value of education and training local anesthesiologists who then can become leaders in their country.  

The efforts in Guyana are similar, they’re not quite as far along, but there is now a Guyanese anesthesiologist who is in a position over all the graduate medical education in the country and another anesthesiologist who is now head of the Guyana anesthesia society and training program.  Again, similar thing, they started with not too much and are slowly growing.  Those are really exciting things that our committee has done.  

Another thing, 5 of 6 years ago, I started a program within the GHO committee where we send senior-year U.S. anesthesiology residents to a low-income country for a month to get to experience what it’s like to live and deliver anesthesia care in another country.  Not so much as a mission model, you go for a month and do work, you start to understand what the educational needs and systems are.  Each year we send 6 or 8 residents, we have now sent 50.  Started in Ethiopia, and now Uganda and Malawi.  

We also sponsor visiting scholars to come to the ASA meeting every year, to spend a little bit of time as an observer, to hopefully build some long-term relationships to help them in their development as leaders of anesthesiology programs in their home countries.  

One of my goals is to gain visibility within the ASA about the importance of this work.  Believe it or not, is not universally understood with U.S. anesthesiologists that there is need or value for working with others around the world.  There are definitely people who want to make some humanitarian contributions but don’t really know how to go about it.  

I have a couple of other things I’m working on.  There is an organization called the World Federation of Societies of Anaesthesiologists.  Basically, a society of societies.  Any country that has a society of anesthesiology can be a member of this.  They have separate committees.  Some provide educational opportunities.  There is one in Nairobi, in pediatric anesthesiology, those travel and spend time at Kijabe.  There are other programs around the world in pain medicine, and other stuff.   WFSA does a lot of advocacy work.  They do work preparing statements in line with WHO guidelines, helping member societies advocate for and navigate local politics.  I just became part of the larger board of directors.  

David: That’s lovely.  I have met several of the visiting pediatric anesthesiologists.  That work is what makes a program like this PAACS thing possible.  It’s not only a matter of education; it’s creating an environment where people can succeed after they have that education.  Good on you, thank you!

Elizabeth: It’s true in our US hospitals and training programs, so why would we not think it’s important in the rest of the world?  It’s one thing to train people, it’s another to sustain them, maintain them, help support them in their career growth.  In many parts of the world, anesthesiologists might be the only one in a community or in a large geographic area.  We need to find ways to support them – simple things like continuing education, how to learn new techniques, how to have collaboration/cooperation when you have a difficult case, how to work together to improve not only educational systems, but care systems, how to lobby ministers of health and education.  These are difficult things, even for those with a lot of resources.  

David:  I don’t know how big you want to go, but you are definitely familiar with Africa. . .what is the picture of the need for anesthesia in Africa?  

Elizabeth:  I think it’s safe to say, the need is probably overwhelming and staggering.  If you could actually think what the need is, you could get depressed, thinking how would we ever meet the need?  

The standards that organizations like the WFSA advocate for are in terms of how many providers you need per population.  

In terms of a place like the US, we’re way above recommended minimum which might be 10-20 surgeons, anesthesiologists, obstetricians per 100,000 population.  

In many countries in Africa, those are in single digits.  For example, Ethiopia, which has more than 100 million population has a couple dozen anesthesiologists.  On any given day, there are more than that at my one hospital in the United States.  Kenyan and Uganda are a little better, but not a lot.  Most of Sub-Saharan Africa, which is what I’m most familiar with, has such a lack of anesthesiologists.  Even if you look at other anesthesia providers, whether they are nurse anesthetists or KRNAs or different names that are given to non-physician anesthesia providers. . .even when you count those, they are not enough to care of the population. 

First and foremost, we have got to find ways to increase the numbers of providers.  But that in itself is not sufficient.  You need numbers, but you need quality care.  In addition to that, you need the support systems.  You need a hospital that has water and electricity and understands the basic concepts of sterile technique and infection prevention and control, and quality & safety systems that support surgical care.  Then you have to have pre-op and post-op care.  You need nurses and you need ways for patients to get to a hospital.  You need to figure out which hospitals should be doing which types of surgical procedures.  Each country has its own political and governmental ways that’s organized.  There are certainly limitations in what is available.  

There is a never-ending need.  You can easily get overwhelmed with thinking about the need.  When that gets too overwhelming to me, I like to back off and think, what can we do and how can we make an impact? 

Taking care of one patient is one thing.  Teaching someone else to take care of that patient is a secondary thing.  Then teaching people how to teach other people to take care of that patient has a magnifying effect.  And then helping anesthesiologists, among others, understand what it takes to make that whole system is important.  A surgeon can’t do it alone.  Anesthesiologists are an important part of the whole team that needs to provide excellent peri-operative care.  In too many situations, anesthesiologists and others are an afterthought.  

David:  This is something I was ignorant about.  What is the role of an anesthesiologist in a developing country?  It’s a lot broader sometimes than what it is in America, right? 

Elizabeth: The American medical education system is a little different from many other countries in the world, even Western countries.  The length of education, the responsibilities, how it’s organized and paid for.  It’s a different system of how care is delivered.  In the United States, in academic medical centers with trainees, there is always an anesthesiologist available, so a resident who is a trainee is never caring for a patient without supervision of a fully trained anesthesiologist.  Our medical education hierarchies are pretty well described.  And the delivery of care is pretty well structured and organized.  That is not necessarily true in most LMICs.  

There are different levels of anesthesia providers who are doing the best they can with the education they have and the tools, equipment, medications that are available to them.  But in a place like rural Ethiopia, for a population of 1 million in one area, there might be one physician, and that’s not an anesthesiologist, that’s a general practitioner.  In the way that a physician cannot be responsible for all the medical care, there is certainly no way an anesthesiologist cannot be responsible for all anesthesia care.  The same is true for surgeons.  

So, you have rural hospitals, whether they’re called district hospitals, or whatever, you can get basic medical care.  If you show up with a broken leg or an infection, you may get some level of care.  You might get some antibiotics, or your infection cleared out, or a cast for your broken leg.  If you need something more sophisticated, you have to go somewhere else.  Anesthesia care is the same way, the most highly trained anesthesia professionals are usually in the big cities and in big hospitals, which means the rural areas are less well-served, not only by anesthesia providers, but by surgeons and nurses and equipment.  One of the challenges is One of the challenges is finding a way to provide the needed care in the rural areas and matching all the needs together.  It doesn’t do you any good to have a surgeon but no anesthesia provider, or the other way around, an anesthesia provider with nothing to do because there is no surgeon. 

One of the things that has become evident over the last decade or so is - what is the bare essential minimum?  The Lancet commission describes Bellwether procedures.  They have a list of procedures that are the minimal procedures you want to be able to do in a district hospital, not a tertiary care hospital.  Things like treatment of abscess, putting a tube in if someone has a collapsed lung.  If your hospital can do these three things, you can probably meet the basic needs of your community.  These are emergency c-section, fixing a leg fracture that requires operative intervention, and doing emergency surgery for an abdominal issue.  

If you can do those three things, and have the anesthesia team, you can meet the surgical needs of the community at a basic level.  None of that is necessary glamorous.  It’s not plastic surgery.  It’s not elective.  It’s basic surgical needs, and if you can meet those, you can meet the needs of the community.  Those are the goals that governments and institutions are working towards – how can we provide those basic needs?  

David: In Kijabe, for the developing world, we are a pretty advanced setting.  What does somewhere like Kijabe make it worth investing in for these training programs?  We are in the in-between space.  We are rural, but not super-rural, you can get to Kijabe in an hour-and-a-half from Nairobi.  Is Kijabe an ideal set-up, in some ways, as you look at the training sites you have been involved with.  What makes you happy about what we are starting out with?  

Elizabeth: A couple of things.  Clearly, the basic infrastructure exists at Kijabe to provide comprehensive care to a whole population.  That’s from birth to adulthood.  That’s from basic outpatient needs to complex surgical intervention that requires intensive care afterwards to survive and get back to health.  In that sense, it’s not a rural, remote place that does a few things, but it has comprehensive care.  It doesn’t offer everything to everybody that a bigger city might, but you don’t need everything, everywhere.  

From that sense, it’s really a good way to look at what does a population need in order to not only meet the basic minimum, but to try to use the advances in medical and surgical care to improve someone’s health, not just react to when you fall and break your leg or infection, but how can we try to promote health among a population.  

Kijabe allows people who are learning and training, and people who are more advanced in their career, to see the value of working together in teams and partnerships.  For too much of medical history and training in America and many Western countries, there are hierarchies and traditions of who is in charge, and who has the power, and who gets to make the decisions which may or may not be in the patient’s best interest – a culture of education and training which is not necessarily supportive and positive.  Those things are slowly coming to light and being addressed in American medical education, although we have a long way to go, IMO.  

I think, in a place like Kijabe, the camaraderie people develop by living and working together in a small community and over a long period of time shows the value and benefit of partnerships and collaborations and working together to try to improve the health of your community. . . 

In a place like Kijabe, having anesthesiologist training will help show that physician anesthesiologists and non-physician anesthesia providers can work together collaboratively.  There are too many examples around the world where relationships of different providers are antagonistic.  It happens among anesthesiologists. It happens among another health care professionals.  In a place like America, where there are other factors at play, politics and finances, it detracts from the care that patients need.  

There is value in people seeing the benefit of collaborative relationships.  For much of medical history, surgeons and anesthesiologist haven’t always been collaborative and working together.  Some hospitals have better cultures than others, and it’s clearly beneficial for patients if they work together, but that’s not always the case, so that has to be modeled.  Same between specialists.  If an EM physician asks for help from a urologist or general surgeon and the attitude is “why are you bothering me?” nobody benefits from that.  In a place where everyone is in it together, people learn this attitude.  

Another thing that Kijabe is working towards is finding ways to train people to go into communities where there is not the level of care that Kijabe offers.  That’s a tricky thing to teach someone to do.  You want them to have every benefit, but you want to train them, “what happens when you to go into an area where you don’t have all this stuff?”  That’s true in America, that’s true in Africa.  

It’s difficult, it’s not a simple formula.  It does help remind you to learn the basics, and how to do no harm, how to prepare and advocate for what you need.  If we train these people and they all end up in Nairobi, it doesn’t do any good for the rest of the country necessarily.  Finding that balance is difficult, and it’s going to take thoughtful dialogue among leaders about how to meet those needs.  

One of the things that some of the training programs have in Kijabe have worked on is to train people to go to other places in Kenya and other places in Africa where there are not so many.  If you can provide a team, a surgeon and anesthesiologist and other support staff, for an operating room at a hospital, that’s what you need.  

David:  Your answers made me really happy.  It’s easy for someone like me to overlook the culture of collaboration.  When I had surgery a few years ago, Mark [Newton] did the anesthesia.  Mark called Mike [Mara], the orthopaedic surgeon, and Mike called Rich [Davis], and they’re all together working with me, and they’re all friends, together working on me.  I haven’t thought, until you said this, what it means to be living together in this community as neighbors.  It’s fun.  It will be interesting to see who are the first residents in the class.  We go to their kid’s birthday parties.  It’s a special place to get to know each other on many and deep levels. 

Anything we should talk about to wrap up? 

Elizabeth: We just had a series of interviews for applications in the first class of trainees.  Hopefully in the next weeks and months, we’ll be able to move ahead with selecting our first two trainees.  Our initial goal was to start this month, but because of COVID, government regulations, we’re not there, but hopefully this year we’ll be able to start with the first two.  

We have to balance the needs, to train those two well, and make sure we support them.  It’s a beginning of the journey, not the end, many more trainees who can train other people, who can go out and provide care that needs to happen around the world.  

David:  I speak on behalf of Kijabe when I say this, we are grateful to you for your support and advocacy in getting this program to where it can take off.  Thank you.