Looking back on a long and storied history of medical breakthroughs, we're inclined to remember the discoveries that take the form of lifesaving solutions: penicillin, the polio vaccine, radiotherapy, antiretroviral drugs. Our minds turn almost naturally to the game-changing inventions designed to cure or prevent disease; rarely do they conjure up those that sow the seeds of a whole new playing field.
Such is the story of modern anesthesia, first administered in Boston on this day in 1846. If surgery was the game-changing solution to save or improve lives, anesthesia was the discovery that allowed the game (as we know it) to be played in the first place. And it's only fitting that we rarely remember its role.
Anesthesia is the intervention needed to sedate patients for surgical operations, typically consisting of four elements: anesthesia (loss of consciousness), analgesia (inability to sense pain), anxiolytics (relief of fear or agitation) and amnesia (loss of memory). Depending on the surgery, anesthesia is most often delivered as an injection, a topical agent or an inhaled vapor - all of which are common, safe practices available to almost everyone in the U.S. But for billions of patients around the world, it is anything but common, and often unsafe.
"Modern" anesthesia was first tested successfully by two doctors on October 16, 1846. They created a chemical compound called ether that was more powerful than the nitrous oxide they had been using, and unveiled their discovery publicly at what is now called the "Ether Dome" on the campus of Massachusetts General Hospital. Afterwards, high-income countries began a steady march toward safer and more effective methods, and today, these countries have developed advanced anesthetic medicines and high-functioning surgical systems to care for their citizens. But low- and middle-income countries (LMICs) still face widespread challenges in delivering anesthesia for surgery.
Approximately five billion people around the world - the vast majority in LMICs - still lack access to adequate surgical and anesthesia care. Last year alone, nearly 17 million of them died from a condition that could have been treated or prevented by surgery. Millions more suffered disabilities or injuries that were left untreated.
Global surgery and anesthesia experts tend to point to three major factors that contribute to this tragic gap in anesthesia care.
First, there's the technology factor. Functioning anesthesia machines are hard to come by in the developing world, often due to infrastructure limitations at low-resource hospitals (such as unreliable electricity and compressed oxygen) or the fact that most medical equipment is donated and left inoperable once it needs a repair or spare part. In addition to the lack of viable devices is a dearth of "consumables" they require to deliver anesthesia: anesthetic drugs (which can be expensive to procure and challenging to distribute), sutures, tubes and masks, filters, gauze and the like.
Related to anesthesia technology is the workforce needed administer it. In the U.S., there's more than 10 anesthesiologists for every 100,000 people; in the Democratic Republic of the Congo, there's 0.02 per 100,000 people. Some countries are hit particularly hard by the trend of talented medical specialists who earn degrees locally only to seek out higher paying jobs elsewhere. Because of this and other educational and professional factors, many countries face such a shortage of anesthesiologists that they rely on nurses to anesthetize patients, inhibiting the type and quality of anesthesia they can offer.
The third leading factor affecting global anesthesia care is policy - and the lack of data necessary to inform it. Confronted with the urgent need to battle infectious diseases like HIV/AIDS, malaria and tuberculosis, governments in LMICs have traditionally prioritized policies to target specific epidemics. But, thanks in large part to the Lancet Commission on Global Surgery and less-disease-specific trends in funding, that paradigm has changed in recent years. There is now a growing body of global, national and sub-national data on anesthesia and surgery that has begun to quantify the problem and influence countries to invest in systems to overcome a new generation of health issues - many of which hinge on better anesthesia and surgical care.
If there's one suture that stitches the above factors together, it is the recognition that anesthesia does not hold the revolutionary appeal of penicillin or the immediate treatment power of antiretroviral drugs: it is as much a game-changer as it is a game-enabler. A century and a half since it enabled its first surgery, anesthesia is as critical a medical discovery as any. Now, it is imperative that we make it a staple of every health system - remembering its central role in surgery, even if its patients can't.