No Opiate Analgesics All over Sub-Saharan Africa

Safe and Sustainable Anaesthesia in Africa and the developing world: finding ways to share our Knowledge and Goodwill



I profile an alarming shortage of trained Anaesthetists in Sub Saharan Africa and the immediate impact of this on peri-operative safety.  In the worst affected areas the maternal mortality in childbirth is estimated to be 1 death in 12-20 operations.    We focus on efforts to promote safe anaesthesia by training nurse anaesthetists and to ensure access to basic, essential equipment (e.g. pulse oximeters) and WHO approved core drugs.  The frontline anaesthetic is ketamine reflecting its safety margin and a chronic lack of opiate analgesics across a vast region. The simple goal is to export the techniques we have used for 150 years.  Everything from condoms and perfusion sets must be re-cycled and there are often no blood banks or adequate reserves of magnesium sulphate for eclampsia. We profile the response of the AID agencies and highlight the sparsely resourced organisations helping in this humanitarian crisis.  Potential funding sources are explored to support self-sustaining training programmes, to empower clinical leaders in Africa and to refine and endorse the uptake of Standard Operating Procedures (SOPS) for safe anaesthesia.  Barriers to safe and sustainable practice include HIV, malaria, TB, peri-operative sepsis, inefficient logistic support and a lack of trust between developed and developing countries.  All are surmountable but efforts are often confounded by ongoing violence in a perpetually turbulent continent.  Lastly we explore the concept of “academic & practical impact” of the aid/training/research programmes and the paradox that funding to provide clean water, jobs, equipment and exporting safe and effective practice (which we have deployed for decades in Europe) for huge numbers of African people is not a high priority.

The issue was first brought to my attention by Channel Four News

VIDEO CLIPDesperate need for trained personnel and drugs that we have taken for granted for 200 years

Here is the full paper that I prepared with the help of friends who give up their time to go work in sub sharan countries at great risk, often as a surogate for their vacation and as an essential step in the training of maternity nurses in techniques and the use of drugs tools we have taken for granted for circa 200 years in developed countries where the death rate for mothers in obsteric operations  is something like one in 180,000 (after raising funds to get them out their and to help supplement the kit/infrastructure in impoverished countries).  The editorial board at a leading Journal in Anaesthetics/Intensive Care  would not accept our article for publication (or peer-review/refereeing) in the academic journal so I have taken the co-authors names off for fear they get heat from their employers (who think, like the editorial board,that the article is too political to be published in an ENTIRELY ACADEMIC OUTLET)!  I am unpaid and unemployable because I condemn the running of narcotics into civilised countries by the leaders of those countries and their INTEL agencies/even their armies so, here are the consequences for the people/women & children  of those countries on a massively under-resourced Continent. The draft was prepared by anaesthetists, NGOs/charitable workers and healthcare professionals with experience of Africa and of the conditions there. If any of the drafts co-authors* want to be named then please get in touch but, for the moment, if this remains politically incorrect, I have removed your ID and your Institutional address.  If you do stray on the article please look at the surrounding web site pages and KNOW where the anaesthetics, opiates, analgesics, narcotics (that could be used to end the suffering across vast regions of the developing/third world) actually go and who profits by/suffers for it.  This policy of trading medicinal solutions as recreational narcotics for developed countries in war and in peacetime is the policy of national governments and monarchies right at the head of World Governance and it needs to be outed and stopped so poor people on vast continents can have a life and a baby SAFELY.  

Focus Article: 

Safe and Sustainable Anaesthesia in Africa and the developing world: finding ways to share our Knowledge and Goodwill.

George Lees BSc Pharmacy, PhD Pharmacology (and several anon contributors/co-authors)*

KEYWORDS:  Anaesthetic and Analgesic Safety

                         African Obstetrics and Surgical crisis

                         World Health Organisation core drugs

                         Nurse Anaesthetist  Training Programmes

                         Funding for Sustainable Practice

                                 Impact and Ethics

1. Introduction

During the protracted wars and violence  in Liberia  (the last conflict ended in 2003), many medical personnel, physicians and anaesthetists lost their lives, fled the country or just left to better their socio-economic prospects. In a country of approximately 3.6 million people and with refugees entering from war torn neighbouring countries like the Ivory Coast, it is immensely difficulty to provide safe anaesthesia under the prevailing circumstances1.  Liberia has only 22 trained nurse anaesthetists across the whole country, many of whom are nearing retirement (and estimates suggest that only 25% of hospitals there have access to a trained anaesthetist).  The horrifying consequences of this are that approximately 1 in 121 to 1 in 202 mothers die in childbirth in Liberia.  All Across Sub-Saharan Africa more than 100 children die (per thousand live births) under the age of 5 years but encouragingly these statistics have improved over the decade up to 2009 (only Chad reports over 200 deaths in 2009)3. The statistics cited above from the United Nations International Children's Emergency Fund (UNICEF) and the World Health Organisation (WHO) illustrate how life expectancy and per capita income in Africa has lagged behind the encouraging trends in the Developed Countries and this is graphically illustrated over time on the gapminder website4.  Life-expectancy at birth for women in the developed world is 78 years and rising5 according to the WHO but in sub-Saharan Africa, with the emergence of HIV (Fig 1), it is less than 54 years for men and 57  years for women.  Public Health statistics in the developing world  are notoriously inaccurate  which is a fundamental confound for the development programmes and for measuring the impact of International aid6.  In West African regions mothers suffering from vesico-vaginal fistula are successfully treated by skilled medical teams on African Mercy ships and in the Aberdeen Clinic.  The mercy ships play a significant role in not only access to safe surgery but also in the training of local healthcare personnel and liaise on onshore capacity building with inspirational local leaders6a. The Liberian situation and the sexual violence which occasionally flares up in neighbouring countries, notably Ivory Coast, is a neglected crisis for womankind and needs to be quickly brought under the radar of the lobby groups and charitable organisations that are fighting for such worthy causes.  WHO statistics, suggest that even in Liberia, the morbidity and life-expectancy statistics are improving (which suggests that local leadership and International aid are positively impacting) but this is frustratingly slow even 8 years after the most-recent conflict there7.  This progress must be balanced against the escalating threat of new wars or natural disasters all over the world (in both these arenas organisations like Save the Children and UNICEF8,9 play vital roles).  The need to deploy patch up AID repeatedly in insurrection or war reflects our incapacity to absorb the lessons from the historical archive on the issue of global conflict e.g. 10.   The malign influence of violence and warfare on women’s health has had a telling influence across the globe and has historically taken its toll notably in imperialist, occupied, or strife-riddled countries11.   Across Africa as a whole, preventable anaesthetic related deaths are running around 1 in 100 to 1 in 50012,13.  In the UK, where we (the public at large and well meaning action groups) worry about “the basic human right” of access to a spinal anaesthetic in obstetrics14, preventable anaesthetic-related deaths were around  1 in 180,00013,15.  Obstetric deaths in the UK, encouragingly, have fallen from 13.95 per 100 000 maternities in the previous triennium to 11.39 per 100 000 maternities in 2006–0816.  These statistics suggest that, in the UK , we are in a safety zone of expert healthcare that the rest of the world cannot sustain.  Both in Africa and the UK, haemorrhage, sepsis and eclampsia are important factors. In many regions across Africa, blood donations come directly from family members (there is no blood bank, or time to screen for HIV or malaria and the abuse of young children is disturbingly prevalent, so transfusion, is fraught with danger).  (Fig 3 Near Here) Perfusion sets often have to be disinfected and re-used and the availability of Mg++ is restricted.  In countries like Gambia17,conscientious local and national leaders, trained anaesthetists and International educational/training programmes  are positively impacting on patient care.   Elsewhere in Africa, the lack of trained personnel is an ongoing problem but we hope that the goodwill can be created between neighbouring countries to share best practice and to, in this way, arrest the exodus of skilled professionals to the developed world. 

Patchy access to dated equipment for anaesthesia and monitoring (pulse oximetry is as hi-tech as it gets) is still a major issue.  There are initiatives to expand availability of low cost oximeters18. The programs are not yet well enough resourced to make it possible to provide free oximeters and there is some way to go (over 77,000 operating rooms worldwide still have no pulse oximeters to monitor patients according to the lifebox website)19 .  The distribution of tools that we take for granted is still in its infancy and one hopes the medical device and consumables manufacturers respond to this constructively in what is a huge untapped market.  There are rarely any technical staff in the region who can service, repair or replenish the donated equipment.  The concept of logging the services and adherence to approved standard operating procedures (SOPs) is impacting  in Sub-Saharan Africa now:  in Uganda, training to ensure compliance with safe SOPs has reduced mortality by about one third. We are aware that UK teams are training nurses and non-medically trained staff (able lay persons, normally female) as skilled birth attendants who can readily recognise warning signs. Nevertheless, there are only 350 trained anaesthetists in Uganda with a population of over 50 million20.  The Association of Anaesthetists of GB is funding “bonded” courses to upskill 11 medically qualified anaesthetist (to complement the 13 clinically qualified anaesthesiologists already working in Uganda). Training courses are slowly impacting on disinfection too.    

Throughout the sub-saharan region, access to drugs is limited and many hospitals cannot access WHO core drugs.  There is funding for drug procurement from the Global Fund, co-ordinated by the National Ministries of Health in liaison with the Aid agencies.  Dissociative anaesthesia21, with a better safety profile, is the most widely used in Africa reflecting the sad fact that opiates (with their much narrower therapeutic index) are largely unavailable22.  So this is a primitive and frightening concept but amputees (and all who require major surgery) often have to be restrained without pain relief.  This is the same situation that the whole world had to live with 150 years ago but it seems inexcusable now that we know the secrets of effective clinical practice. 

Corruption, capital flows, and the incapacity to generate stable jobs or substantive tax revenues  confound progress on the ground but objective statistics are lacking. The World Federation of Societies of Anaesthesiologists (WFSA) represents 122 Anaesthetic Societies across the globe. The WFSA (and its affiliate the World Anaesthesia Society: WAS)  has co-ordinated and catalysed  efforts to expand and consolidate this training base.  There are too many centres and skilled tutors (selfless clinicians, nurses, pharmacists, logisticians, NGOs  and academics) to list or name them all in such a brief review.  Much of the work is conducted by registered charities using staff who raise grants or donations to buy out time from their state health service.  The authors of this review work in post graduate educational refresher courses on anaesthesia, critical care and pain relief or in close liaison with the registered charities  “Mothers of Africa”  ( main areas of work are Liberia and Benin), Scotland-Malawi Anaesthesia, Mercy Ships and the  Irish Women of Malawi charity.   The Advanced life Support Group and the Obstetric Anaesthetists Association have also delivered such courses in developing countries throughout the world.  Other key players include the Royal College of Anaesthetists (providing funding and administration for multi-disciplinary refresher training in Somalia and Uganda the obstetrics training programme and the Advanced Life Support in Obstetrics courses that have rolled out in Malawi for midwives and obstetricians).    Most of these organisations are sparsely funded although encouragingly grants up to €600,000 have been raised in the recent past. With input from determined inspirational figures like Ann Gloag (who trained as a nurse) the Mercy ships are run on efficiently resourced business models using skilled unpaid volunteers from many countries delivering broad spectrum expertise from agriculture and forestry to oncology and surgery. The MERCY ships help with capacity building onshore and funds are raised by sponsors who provide expertise in extracting mineral and oil reserves in the participating countries 6aAnaesthesia and drug safety overall is a big priority for the WHO (and the International Society of Pharmacovigilance or ISOP) and have significant funding and leverage for local support in Africa and the Middle East.   One hopes that International links can be integrated further to make a justified case for funding from the United Nations Development Programme (UNDP) and the United States Agency for International Development (USAID).  Effective pain relief22 is considered essential in the western world but this is seldom available in the developing world.  So Africa lags behind in meeting CORE targets for the WHO, including access to medicines on the essential drugs list (EDL) but objective, highly cited research on this is difficult to find. Whatever the reason, drugs at the top of the analgesic potency  ladder are seldom available in hospices23 or hospitals24 . It is a fundamental paradox that all of the world’s opiate trade is diverted out of the developing countries   (in the Asian “golden triangle” and the world’s largest producer Afghanistan) into “developed” countries.   This creates major societal problems for the developed world and concurrently deprives patients, all over the developing-world, of perio-operative pain relief which we currently take for granted.   The costs of policing this issue, in terms of human life and taxpayers revenue24a, are massive.  Inspirational International leadership can quickly change the mindset, end the fiscal crisis and make enlightened visionary leaders iconic figures in establishing global civilisation.

The current G8 approach to restoring peace in Africa, bizarrely funds the violence concurrently with major and benign healthcare interventions (so there is support to patch up the collateral damage but limited scope for sustainable development without constructive policy change from all parties).  If the local experts struggle in obstetrics when peace has broken out, then one can only imagine the working conditions for AID agencies like Medicine Sans Frontieres ( in the midst of the violence in revolutionary/war zones)25 .  MSF were awarded the Nobel peace prize in 1999 and details of their programme are on their website25.  We are flirting with academic and research conventions by not citing scholarly articles (simply because there are very few indeed and are infrequently cited) but to give the readership perspective on conditions on the ground, we refer them to an Oscar nominated movie “Living in emergency: Story of Doctors without Borders”.  The heroic staff portrayed in the film are not actors26.  Those featured are being filmed in the field and the film is uncensored which, in itself, is unusual in the war zones because of the risk of capturing propaganda on camera or manipulation of the footage for political advantage.    MSF works in more than 60 countries worldwide with almost half in Africa (the data presented here were collated in 2009 ). Out of a total of 23,000 staff worldwide (more than 90% of whom are national staff), 16,000 were in Africa .  Estimates, in 2009, suggest that about 26% of MSF staff were doctors, and 31% were nurses or paramedical staff and these efforts would be ineffectual without the efforts of logisticians, fundraisers and administrative HR staff.  Feedback from the organisation suggests that UK anaesthetists are typically able to engage for two- three month periods; more rarely six months. Out of a global income of 665 million Euros, 69% was spent in Africa: 90% of MSF funding is private which gives them independence of action and neutrality in conflict zones. The funds are raised from public donations in the street or shopping mall, although there are millions of regular donors who support MSF with long standing personal donations from year to year. MSF are funded in part from the EU government (very limited) for very specific projects. They do not draw funds from the US or French government. The Global Fund, do not fund this work directly but in some projects where MSF work in partnership with the National Ministry of Health, drugs for HIV, TB or malaria programmes are provided from this vital funding source.  There are many other organisations out there working in war zones including the International committee of the Red Cross (ICRC), Oxfam and Save the Children. The MSF strives to avoid duplication by coordinating with other organisations but it is difficult to achieve perfect and timely responses across the troubled regions.  We hope that clinical and civic leaders all across the sub-Saharan region can create a cohesive method-sharing network to develop and attract local talent and that the benefits of investing in endogenous training programmes and local job creation can, in itself, quickly bury the myth that civilisation and political popularity can be sustained by force.  As a general rule, for the sake of independence and neutrality, MSF do not collaborate with armed forces (even when they provide humanitarian aid) to avoid being associated with political, military, economic or religious powers. Also, as an emergency humanitarian organisation, they do not get involved in conflict resolution but strictly focus on alleviating the suffering of those affected by the violence.  MSF do not operate in a political vacuum though, they do talk to ministries, military staff, rebels, opposition groups to explain their position in treating the patients suffering their clinics (beyond the wounds and diseases that are treated). Giving a voice to patients is a very important component of action in the field (as in all the developed countries).  So, long may these efforts continue in natural disaster areas but prevention has always got to be better than cure when it comes to warfare, insurrection or outbreaks of violence. There is a vital  role for national and civic leaders in creating this trust and making their country attractive to healthcare experts wherever they have trained (the societal and capital costs of migration and asylum is fast becoming a headache for politicians) and benign, visionary leaders can become local heroes by leading their countries out of austerity.  The painful lessons of history indicate that only peaceful co-existence and integration, can establish trust, then allow society, healthcare and democracy to thrive. 

 Funds to take on the nurse training, educational programmes and to support the aid agencies are hard to come by and it is disappointing that such readily achievable goals cannot be resourced adequately (the teams are simply seeking to export safe established practice that we have enjoyed for over 150 years).  Those that are engaged in training from the UK are often funded by our professional organisations to buy them out of their NHS commitments but funding rarely exceeds five figures (£/$/Euros) and frequently the field teaching has to be postponed or downgraded because they cannot be adequately or consistently resourced . The Global fund is invaluable in supporting many worthy causes and increasingly, charitable organisations are fundraising and providing aid or funding raised from donors in both Hemispheres .  The Global Fund notably supports research in Tuberculosis27, Malaria28, HIV29 and in sexual health in general30. These interventions have been effective in making both therapeutic or prophylactic management more widely available. There are also ambitious funding programmes for drug discovery and to overcome resistance to other drugs31 but not so much for just providing access to safe sustainable practice.

Regarding the training of African nurse anaesthetists, at the moment there are insufficient resources to create a self-sustaining system, that will permit safe surgery for all, but capital building projects have been funded in various locations and training courses are beginning to produce safer and more widespread availability of Anaesthesia.  For example, in Malawi where the concept of endogenous sustainable practice is no longer a distant vision, new hospitals have been funded and built32    In Malawi too, there are now approximately 91 Anaesthetic Clinical Officers (each course caters for 16 trainees).  Unfortunately, in Liberia, recruitment of trainees is very difficult for the following reasons. To enter the nurse anaesthesia training programme you must have completed 2 years training (as a nurse) and then usually have two years experience working as a nurse. You then enter the programme where you don't get paid BUT when you pass the programme you are paid the same rates as a nurse working on the ward. So there are no obvious incentives to participate other than personal conscience and ambitions  to improve the  anaesthetic and obstetric mortality statistics. There are two endogenous anaesthesia programs in Liberia :the JFK and the Phebe anaesthesia programs.   Presently there are 11 students in the entire program (4 juniors and 7 freshmen) and, encouragingly, UK anaesthetists are expanding access to training in these centres and also  from the Mercy ships .The inequalities in the developing world are bewildering but to recruit to these programs one needs to provide only small amounts of cash as an incentive: the median income in Liberia is less than $500 US/year (amongst the 5 poorest countries in the world (Figure 2 near here)).  The sums donated by philanthropic organisations to worthy charities are on a bewildering scale and the Gates’ fund contributed/pledged $3.5 Billion between 2003-2007 but came a not very close second to Warren Buffet (almost $41Billion over the same period).  The Keywords used to attract support from these benign funders are: for Gates; Global Health and Development, education and for Buffet; Health, Education and Humanitarian Causes.  Anaesthetist, meet ALL these criteria, have the NHS/western medical statistics in their favour and refined clinical protocols but seldom land substantive funds. The issues are big (many of the sub Saharan hospitals fail to meet the WHO standards for care and cannot provide the drugs for effective analgesia)33.  In this environment, most surgery is emergency not elective.  Nevertheless, over-time, training and relatively sparse funds for resources and personnel can create sustainable practice.   One wonders if Institutional profile or the lack of publication “impact” accounts for the paucity of funding but the timing is perfect for National and International leaders to make benign forward-looking gestures in these troubled and impoverished regions .  Life expectancy, health, birth rates and per capita prosperity are intimately linked and the AID and training programs can kick-start a new era of stability and political popularity for inspirational African leaders 

“Impact”in research is difficult to define or quantify, but it has become an altar to be visited frequently by academics and politicians in the developed world.  They know that there is a god to be worshipped here and that she/he is appraising their career performance.   Those anaesthetists who heroically step forward as volunteers to tighten their belts for a period of secondment to training in Africa, are in there to get an invaluable job done and writing papers on this mountainous task is clearly of lesser importance than establishing safe practice “hands on” (what shines through all the feedback to us is the exhilaration derived from involvement/progress in the field). Heroically, all volunteers just get out there to help in theatres and deliver the educational programmes which have been profiled elsewhere in this article.    Peer and media pressure, as well as popularity, are important facets of another complex issue (and “celebrity” and “impact” are deities that go hand in hand) but one hopes that morality, visionary leadership and collaboration will prevail then  permit safe and effective practice to thrive across the continent, despite in the current situation.  Heretical or no, “impact” is increasingly important for academic status and career progression.  Running a search on the big picture issues here (linking the terms “Anaesthesia or Anesthesia”) achieved more than 100,000 hits, too many for the software to count.  BUT searching within these for Africa, overall years returned only 109 publications and many covered veterinary practice: 13 of these have been cited 13 times and the most talked about paper on Global International protocols for resuscitation had 76 citations.  The second paper on the list profiling the training of non-physician clinicians has been cited 43 times (it addresses the training needs of 47 sub- saharan countries).  The exact numbers don’t matter (and vary with search engines and keywords) but the lack of relevance of high  impact factor publications to patient outcomes is clearly a concern for practicing anaesthetists and intensivists.   The most talked about papers from the research in  academic/scientific Anaesthesia or Anesthesia are cited in this focus article34,35,36: all three are non clinical themes and  undoubtedly profile cutting edge science and have been cited a staggering 3943 times.  Seminal publications on the role of Mg++ in pure neuroscience have been cited thousands of times e.g. 37but its importance in the safe management of eclampsia (which is a major cause of maternal morbidity) is unrecognised in terms of research impact. This reflects the emergence of the new church of “reductionism” and themed funding initiatives (much of the big funding and high impact publications are in fields like genomics or wildlife preservation but HIV, TB and malaria are up there too).  So would the agnostics or atheists working and teaching in African anaesthesia be prepared to visit the altar of impact?  I (we*) think they should.  The Global fund, Medical Device Manufacturers, USAID, and UNDF hold the key and if buyout time from the NHS/state contract is insufficient to write an application then academic affiliates may be able to assist with this (and we hope to bring this into the eye of Academic Anaesthesia Departments worldwide).  There is an increased emphasis on translational research from tertiary education funding councils (certainly in Europe and the UK) and it seems likely that academic participantswill get “career credits” for these efforts in the forthcoming research quality audits and International Academic league tables.  Funding of this nature will transform the programs (and increase recruitment of both trainees and academic/clinical tutors).  Research funding in anaesthesia is not easy to come by (at least at levels that satiate the high priests of impact within the academic, political and research funding bodies) but the African work is, in translational terms, “angelic” and the case for support needs to be articulated.  Some years back the whole intensivist research scene was transformed with the increasing risk of terrorism or global conflict and then there was a funding boost for intensive care research on issues like blast, crush and burn injury, and to find antidotes for toxins, nerve gases or biological weapons38, 39, 40, 41.  It is ironic (that to get funded we need conflict or disaster)  BUT the outcomes of research like this are undoubtedly helping our troops, volunteers, civilians and terrorist victims AND access to the refined protocols and the research outcomes can help a lot, particularly if it is shared with MSF, the Red Cross  and the other field teams by publication.  We* are not aware if all the data in military defence institutes from this type of research is shared with the emergency  teams, doctors/consultants on home soil and our allies in conflict?  One hopes that the investment can lead to advancements in practice even if, in future, we opt for peaceful solutions in our foreign policy.  This would have clear benefits for critical care in human conflict but also in solving acute problems presented by natural disaster (we are writing this within months of two massive earthquakes and a tsunami in the pacific and flooding across the globe has become an increasingly frequent and lethal problem).

Sir Henry Wellcome, bravely led delegations into these troubled sub-Saharan regions to focus attention on many of these long standing problems.  He and Sir Henry Dale (the first scientific trustee) rank with figures like Stanley and Livingston in spreading the benefits of pharmacy, medicine and veterinary science across the globe. The mission of the Wellcome Trust is to foster and promote research with the aim of improving human and animal health. The funding influence of Sir Henry’s legacy gets ever narrower and the anthropological consequences of the “modernisation” of the Wellcome Trust remain to be seen.  Wellcome himself believed that sharing best practice across disciplinary boundaries and across the globe was of fundamental importance.  This missionary zeal and the revenues for both research and practice have diminished for a variety of reasons42,43.  The simple implementation of effective and safe practice, which we now take for granted in the developed world, will require much less funding than reductionist but high impact academic research and one hopes that sustainable anaesthetics training and perioperative pain relief can be available soon all over a long suffering continent.

Reference List

1. Deith J (2011) Liberias Desperate Need for Anaesthetists;


3. World Health Organisation, Global Health Observatory web site:

4. Rosling H (2011)GapminderWorld  ($majorMode=chart$is;shi=t;ly=2003;lb=f;il=t;fs=11;al=30;stl=t;st=t;nsl=t;se=t$wst;tts=C$ts;sp=5.)


6.  Setel PW, Macfarlane SB, Szreter S, Mikkelsen L, Jha P, Stout S, AbouZhar C. A scandal of invisibility: making everyone count by counting everyone.  Lancet  2007; 37: 1569-77.

7. WHO

8. Last M (1994) Putting Children 1St. Disasters; 18:192-202.

9. Seal A, Taylor A, Gostelow L and McGrath M (2001) Review of Policies and Guidelines on Infant Feeding in Emergencies: Common Ground and Gaps. Disasters 25:136-148.

10. Chomsky, N (2009). The Legacy of 1989, in Two Hemispheres.  In These Times

11. Gapminder World :$majorMode=chart$is;shi=t;ly=2003;lb=f;il=t;fs=11;al=30;stl=t;st=t;nsl=t;se=t$wst;tts=C$ts;sp=10;ti=1917$zpv;v=0$inc_x;mmid=XCOORDS

12. Maman AFOB, Tomta K, Ahouangbevi S and Chobli M (2005) Deaths Associated With Anaesthesia in Togo, West Africa. Tropical Doctor 35:220-222.

12a Walker I, Wilson I and Bogod D (2007) Anaesthesia in Developing Countries. Anaesthesia 62:2-3. Kinsella SM (2011)

13. Anaesthetic Deaths in the CMACE (Centre for Maternal and Child Enquiries) Saving Mothers' Lives Report 2006-08. Anaesthesia 66.

14. Jolin L, Hughes B (2011) Epidurals (Woman's Hour; BBC Radio4):

15. Cook T, Woodall N, FrerkC (2011) Major complications of airway management in the United Kingdom; NA P4 Report and findings of the 4th National Audit Project of The Royal College of Anaesthetists.

16. Draycott T, Lewis G, Stephens I (2011) Centre for Maternal and Child Enquiries (CMACE), BJOG 118 (Suppl. 1),1-205: DOI: 10.1111/j.1471-0528.2011.02895.x

17. Cole-Ceesay R, Cherian M, Sonko A, Shivute N, Cham M, Davis M, Fatty F, Wieteska S, Baro M, Watson D, Phillips B, Macdonald R, Hayden B and Southall D (2010) Strengthening the Emergency Healthcare System for Mothers and Children in The Gambia. Reprod Health 7:21.

18. Walker IA, Merry A F, Wilson I H, Mchugh G A, O'Sullivan E, Thoms G M, Nuevo F and Whitaker D K (2009) Global Oximetry: an International Anaesthesia Quality Improvement Project. Anaesthesia 64:1051-1060.


20 Grady K, Walker I (2011): Childbirth and Anaesthesia in the Developing World, Womans hour BBC Radio Four

21. Bonanno FG (2002) Ketamine in War/Tropical Surgery (a Final Tribute to the Racemic Mixture). Injury 33.

22. Adenipekun A, Alonge T O, Campbell O B, Oyesegun A R and Elumelu T N (2002) The Management of Metastatic Bone Pain in a Developing Country: the Role of Radiotherapy As an Adjunct to Weak Opioids. Int J Clin Pract 56.

23. Livingstone H (2003) Pain Relief in the Developing World: the Experience of Hospice Africa-Uganda. J Pain Palliat Care Pharmacother 17.

24. Powell RA, Kaye R M, Ddungu H and Mwangi-Powell F (2010) Advancing Drug Availability-Experiences From Africa. Journal of Pain and Symptom Management 40:9-12.

24a McCandless, D (2009) Information is beautiful :

25. Medicines Sans Frontieres: and

26. “Living in emergency: Story of Doctors without Borders”

27. Mukherjee JS, Rich M L, Socci A R, Joseph J K, Viru F A, Shin S S, Furin J J, Becerra M C, Barry D J, Kim J Y, Bayona J, Farmer P, Fawzi M C S and Seung K J (2004) Programmes and Principles in Treatment of Multidrug-Resistant Tuberculosis. Lancet 363:474-481.

28. Attaran A, Barnes K I, Curtis C, d'Alessandro U, Fanello C I, Galinski M R, Kokwaro G, Looareesuwan S, Makanga M, Mutabingwa T K, Talisuna A, Trape J F and Watkins W M (2004) WHO, the Global Fund, and Medical Malpractice in Malaria Treatment. Lancet 363:237-240.

29. Kruger AM and Bhagwanjee S (2003) HIV/AIDS: Impact on Maternal Mortality at the Johannesburg Hospital, South Africa, 1995-2001. International Journal of Obstetric Anesthesia 12:164-168.

30. Lusti-Narasimhan M, Collin C and Mbizvo M (2009) Sexual and Reproductive Health in HIV-Related Proposals Supported by the Global Fund to Fight AIDS, Tuberculosis and Malaria. Bulletin of the World Health Organization 87:816-823.

31. Breman JG, Alilio M S and Mills A (2004) Conquering the Intolerable Burden of Malaria: What's New, What's Needed: A Summary. American Journal of Tropical Medicine and Hygiene 71:1-15.

32.  Hospital Building in Malawi:

33. Lapidus N, Luquero F J, Gaboulaud V, Shepherd S and Grais R F (2009) Prognostic Accuracy of WHO Growth Standards to Predict Mortality in a Large-Scale Nutritional Program in Niger. Plos Med 6.

34. Kim SH and Chung J M (1992) An Experimental-Model for Peripheral Neuropathy Produced by Segmental Spinal Nerve Ligation in the Rat. Pain 50:355-363.

35. Franks NP and Lieb W R (1994) Molecular and Cellular Mechanisms of General-Anesthesia. Nature 367:607-614.

36. Zuk PA, Zhu M, Mizuno H, Huang J, Futrell J W, Katz A J, Benhaim P, Lorenz H P and Hedrick M H (2001) Multilineage Cells From Human Adipose Tissue: Implications for Cell-Based Therapies. Tissue Engineering 7:211-228.


37. Nowak L, Bregestovski P, Ascher P, Herbet A and Prochiantz A (1984) Magnesium Gates Glutamate-Activated Channels in Mouse Central Neurons. Nature 307:462-465.

38. Yanagisawa N, Morita H and Nakajima T (2006) Sarin Experiences in Japan: Acute Toxicity and Long-Term Effects. Journal of the Neurological Sciences 249:76-85.

39. Aylwin CJ, Konig T C, Brennan N W, Shirley P J, Davies G, Walsh M S and Brohi K (2006) Reduction in Critical Mortality in Urban Mass Casualty Incidents: Analysis of Triage, Surge, and Resource Use After the London Bombings on July 7, 2005. Lancet 368:2219-2225.

40. Holcomb JB, Jenkins D, Rhee P, Johannigman J, Mahoney P, Mehta S, Cox E D, Gehrke M J, Beilman G J, Schreiber M, Flaherty S F, Grathwohl K W, Spinella P C, Perkins J G, Beekley A C, McMullin N R, Park M S, Gonzalez E A, Wade C E, Dubick M A, Schwab W, Moore F A, Champion H R, Hoyt D B and Hess J R (2007) Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma - Commentary. Journal of Trauma-Injury Infection and Critical Care 62:307-310.

41. Ressner RA, Murray C K, Griffith M E, Rasnake M S, Hospenthal D R and Wolf S E (2008) Outcomes of Bacteremia in Burn Patients Involved in Combat Operations Overseas. Journal of the American College of Surgeons 206:439-444.

42. Shaxson N  (2011) Treasure Islands: tax havens and the men who stole the world.  Pub: The Bodley Head, London ISBN 9781847921109

43. Klein N (2007) The Shock Doctrine. Pub: Penguin Group, London, ISBN978-0-141-02453-0

 CONFLICT OF INTEREST: The author* has no conflicts of interest.

I sent this to the European Federation of Neuroscience and have published it here because I know the LINKEDIN editor will censor it because it is bad for the GLOBAL business.

 Professor George Lees  commented on How is EEG studied? | Neuroelectrics

 It monitors neural activity unlike ECT which was sponsored for decades by the CIA at McGill for 50 years before it transitioned to Guantanamo. . Will the Lisbon group that got the Nobel prize for lobotomy with an ice pick be represented in these intellectual discussions? I know where your funds are and am ashamed of the narcotics industry... because of this 


I am expecting excommunication but please help give the developing world what we take for granted and for profits Drugs, Booze and Vice: the Fascist links & the French Connection AND NARCOTICS: Opium Wars and Dismembering Vast Continents