Power and privilege in pediatric anesthesia

No one reading this paper will have any surprise that surgical and anesthesia care for children is better developed in Boston than it is in Bujumbura. The gradients in the availability of safe, timely, and high-quality care are steep. For many of us it may be easy to think of these differences as just “the way it is”, or even, not to think about it at all as we go about our day-to-day work of providing the best possible anesthesia care for the children who pass through our own institutions. However, this relatively comfortable perspective may be the result of power and privilege, phenomena notoriously underappreciated by those who benefit from it. In fact, health inequities generally result from the interaction of social determinants of health with fragile healthcare systems and have underlying economic and political causes. The Coin Model of privilege is a useful metaphor.1 The “coin” is a system that promotes inequity. There are two sides of the coin—the same system that gives some people a disadvantage in life that they neither earned (privilege) provides others with advantages that they did not earn nor deserve (often described as oppression). This is simply by an accident of birth, of who that person happens to be. These coins stack, so that some people have privilege in some areas but can be considered to be oppressed in other areas, or may have multiple areas of being underprivileged (sometimes called intersectionality). So where is the power and privilege that affects children who need surgical and anesthesia care globally? What are the “coins” that represent systems that perpetuate inequity? Household wealth is probably the most important social determinant of the health of children and varies both between and within countries. This influences whether the child access to private versus public healthcare institutions with potential privilege in terms of both material and human resources (Figure 1). Healthcare systems have been conceptualized by the World Health Organization (WHO) in terms of “building blocks” including human resources, medial products, and supply chains, information technology, financing, and governance.2 Poorer countries tend to have fragile healthcare systems that lack resources across all of these building blocks. A common theme across the papers in this theme issue was of workforce—Srinivasan and colleagues note the need for increased workforce even in Canada, a high-income country, to “tackle surgical backlogs” and note that most institutions in the US are seeking an additional three or four pediatric anesthesiologists.3 However, the differences between countries are stark. By far the majority of the world's anesthesiologists live in high- or upper-middle income countries (80% of anesthesiologists for around half the world's population).4 The poorer countries in the world are desperately understaffed, with only 0.3% of the global anesthesiology workforce based in low-income countries. The small number of clinicians on low-income countries are overwhelmed with clinical need and face huge challenges with both the training and retention of anesthesiologists that is required to solve this problem. In particular the migration of skilled healthcare professionals from low-income countries to high-income countries, exacerbates shortage of qualified professionals and further weakens already fragile healthcare systems while benefitting the richest countries. What responsibility do high income countries have to compensate low-income countries for these losses? Similarly, in this Theme Issue of the Journal, problems with supply chains were mentioned across papers from countries with very different economies, despite the WFSA International Standards of Anesthesia (published since 1992), from supply chain issues even in the US and Canada3 to descriptions of total lack of essential drugs and equipment in rural India.5 Others of the building blocks were less often noted in this theme issue but are also impactful and vastly different across countries: Rai and colleagues noted the lack of data and information systems on pediatric care in India as well as inadequate financing. Centralization of pediatric care is a theme in recent surgical history,6 and allows the advantages of specialization, but can also result in poorer access to care in rural areas. Not all children receiving surgical care are managed by the teams with the same level of specialization and expertise. Landmark publications of national workforce data globally have been a vital step to progress. However, looking at national aggregates misses many disadvantaged populations. Canada is a high-income country with almost 10 anesthesiologists per 100 000 population, with but her territories of Nunavut, Northwest Territory and Yukon have a combined physician anesthesiologist density of 0.8/1000007 which around the same as the Republic of Zambia (0.7/100000). In this theme issue, authors from upper middle-income countries like Mexico8 note that despite having a physician anesthesiologist density above the WFSA recommendation (7.3/100000) there is a lack of access to specialists in rural and remote areas. India is considered a poorer country than either Canada or Mexico (lower-middle income country), but Rai and colleagues that an urban centers have such a high level of care that attracts medical tourism even from high-income countries.9 At the same time, there is a vast population of Indian children from rural areas who have no access to safe surgical care. Again, the situation is most stark when disadvantages are combined, for example, in rural areas of low-income countries. As of a report in 2023, although Lusaka had over 9/100000 anesthesiologists (the same as Canada) 7 of its 10 provinces had no anesthesiologists at all.10 Other important geographical issues include barriers relating to land-locked nations, small island states and harsh climates.3, 11 Pediatric care requires specialized equipment and training. This makes care for children particularly vulnerable to fragile health systems with variable resources. Training was a consistent theme across the articles in this theme issue. While some high-income (Canada, US) and upper-middle income countries (like Thailand)11 have recently established competency-based curricula for pediatric anesthesia while others have not recognized pediatric anesthesia as a subspecialty.6 Moreover, many low income countries are only beginning to start subspecialty training programs at all. More pediatric anesthesia fellows are trained each year in Canada3 (27/year) than pediatric anesthesiologists in the whole East, Central and Southern African region (22/total).10 Children also tend to be included less in clinical studies so there is often less data on pediatric patients. There are a higher proportion of children in the poorest countries of the world, the median age of high-income countries is 41.4 whereas in the poorest countries in the world, over half the population are children (low-income countries median age 18)12 another example of intersectionality. The burden of disease that is amenable to surgical care is highest in the poorest countries of the world, where there are the least resources. Surgical care, and even broad health system strengthening is often not prioritized over other pathology such as HIV and other infectious diseases,13 despite evidence for the cost effectiveness of surgical care globally14 and that the burden of surgical disease exceeds that of HIV.15 In the US children from minority racial groups have higher rates of morbidity after surgery than white children,16 even in healthy children.17 This is in keeping with maternal mortality data that has found higher rates of maternal mortality in Black women in the UK and the US,18 with poorer quality care.19 The maternal mortality rate for Black women in the US in 2021 (69.9/100000) was higher than the population average for Brazil (60), Egypt (37), or Sri Lanka (36).20 A further example is of the only recently recognized racial bias in pulse oximetry measurements that disadvantage black patients including children shows how deeply imbedded these issues are within the structures of our healthcare systems.21, 22 Although there are few data from pediatric surgery, access to healthcare is gendered23 and initial reports suggest that African girls face gender inequities in pediatric surgical care.24 More data is needed. We must acknowledge the ongoing impact of historical colonialism on healthcare infrastructure and power dynamics. Colonial powers imposed their own healthcare systems, often disregarding local knowledge and practices, and creating a culture of dependency. Lack of cultural sensitivity has led to mistrust and resistance. These many different systematic issues reach across borders to emphasize that global health is fundamentally an equity issue, not limited to any country (or group of countries) in the world. The effect of being on the underprivileged side of multiple “coins” can be considered a form of “structural violence” in that it is an indirect but systemic cause of very real harm to children who fail to access surgical and anesthesia care. Clinicians are generally not trained to understand or influence these social, political and economic factors which result in this harm. Power and privilege remains widespread and persistent throughout medicine and children with “surgical” disease in impoverished homes in the rural areas of low-income countries continue to face a legion of barriers to surgical and anesthesia care. At the same time, those of us on the other side of all those “coins” continue to benefit from systems that are often the legacy of colonialism.25 Collaborations listed in this theme issue have had huge impacts on the development of pediatric anesthesia care globally, including the WFSA supported regional training collaboration between Thailand and Mongolia and many others mentioned by Nabukenya and colleagues.26 These collaborations point the way for interventions to be replicated and scaled up, but remain insufficient. For us, and the next generation, to see a more equitable world in the future of pediatric anesthesia will require a huge investment in scaling up all of the building blocks of strong healthcare systems both within our own countries and through international collaboration. It is most important that this is led by those from the places which are most marginalized and can represent the voices of those children who are most disadvantaged. As noted by Rai and colleagues,5 solutions must be locally driven. National anesthesia societies from low-income countries, the umbrella organization of the WFSA and the grass roots multidisciplinary collaboration of GICS are essential to promote these voice that often remain unheard. Quoting Nixon, “if inequity is framed exclusively as a problem facing people who are disadvantaged, then responses will only ever target the needs of these groups without redressing the social structures causing disadvantages.”1 We must all begin to examine power and privilege, and the structures that continue benefit while oppress others. MD Bould serves as the chair of the Council of the WFSA. H Mumphansha serves on the Diversity, Equity and Inclusion Committee of the WFSA. Data sharing is not applicable to this article as no new data were created or analyzed in this study.

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