Feature BMJ Christmas Appeal

Unsafe surgery: make it zero

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d7773 (Published 30 November 2011) Cite this as: BMJ 2011;343:d7773
  1. Jane Feinmann, freelance journalist, London
  1. jane{at}janefeinmann.com

The BMJ has chosen Lifebox as its 2011 Christmas charity. Lifebox is working to ensure every operating theatre worldwide is equipped with a £160 pulse oximeter, the most important monitoring device in anaesthesia. Atul Gawande, speaking to Jane Feinmann, explains how you can help

How much does it cost to reduce mortality and morbidity in the world’s most poorly equipped operating theatres—while at the same time bringing the surgical teams into a community of excellence devoted to patient safety?

“The answer is smaller than most people realise,” says Atul Gawande, best selling author of The Checklist Manifesto and the lead adviser and authoritative face of WHO’s Safe Surgery Saves Lives campaign.

Just £160 (€186,$250) is the cost of a Lifebox pulse oximeter, a virtually unbreakable, operating room quality version gawande0312 iof the small non-invasive device that is commonplace in hospitals throughout the West. But until now, it has been an impossible extravagance in poor and middle income countries, available, if at all, at an extortionate price with little back up or spare parts. That’s what the BMJ Christmas appeal this year aims to change.

Atul Gwande talks about how donations can help make safe surgery a global reality

“Lifebox is the extra factor that makes safe surgery a global reality,” says Dr Gawande, the Boston surgeon and academic and New Yorker staff writer. Along with world leaders in anaesthesia, he is also the driving force behind the newly formed evidence based charity that has made it possible to deliver a robust pulse oximeter to a hospital in a poor or middle income country for exactly £160.

The pulse oximeter is taken for granted in the West, where every hospital has dozens of these small non-invasive devices that measure the level of oxygen in a patient’s blood during and after anaesthesia—and by sounding an early warning alarm offer the opportunity to prevent brain damage, heart failure, and in some cases death.

“We now know that more than 230 million operations are performed annually around the world and an unconscionable proportion of these are carried out in the 77 000 operating theatres that manage without a pulse oximeter,” says Dr Gawande. “It’s not difficult to find the reason why this is happening. Hospitals in poor and middle-income countries are faced with prices of $2000 or more for an operating theatre quality oximeter—literally unaffordable. It’s estimated that around six million patients every year are forced to receive surgery without a pulse oximeter, substantially increasing their risk.”

Recognition of this dilemma during the creation of the WHO Surgical Safety Checklist triggered a unique collaboration between the founding partners of Lifebox: the World Federation of Societies of Anesthesiologists, the Association of Anaesthetists of Great Britain and Northern Ireland, the Harvard School of Public Health, and Brigham and Women’s Hospital, Boston, under the leadership of Dr Gawande.

“We began by putting the oximeter design out to tender with the requirement that the final product would be made to the highest specification while being suitable for use in low resource settings: robust, durable, resistant to damage, reusable and cheap—and to encourage bidders, we gave an assurance that we could raise sufficient funds for a large purchase of the winning product,” he explains. “Our goal was to give poor hospitals market power. It was an experiment which could have failed—instead it was an extraordinary success.”

Lifebox explain what they do

In under a year, Lifebox has already distributed nearly 1500 oximeters to hospitals in poor and middle income countries, including 1150 devices to Smile Train, the charity that operates globally on children with cleft palates.

Methods of distribution vary according to local requirements. The pulse oximeter is delivered to parts of the world where skilled clinicians simply lack the resources. However, Lifebox and the AAGBI are also organising training in both the use of oximeters and in safe surgery in parts of the world that need greater support, notably countries in sub-Saharan Africa.

With each pulse oximeter being used for an average of 3000 operations every year, a preponderance being emergency caesareans, “the impact of this project on mortality and morbidity will be substantial,” says Dr Gawande.

“‘I am grateful for the BMJ’s Christmas Appeal. It is the first time we have been able to go outside the operating theatre and ask the larger medical world to donate to Lifebox. By donating the whole or part cost of a pulse oximeter, BMJ readers can help Lifebox save lives with safer surgery in poorer nations.”

Over the next few weeks, BMJ readers will have the chance to learn more about Lifebox, through articles, podcasts, and films. Donating is simple; either online (www.lifebox.org/donations) or using the coupon in the print journal, you can help Lifebox in its aim to reduce to zero the number of operating theatres worldwide without a pulse oximeter. Please do give generously.


Cite this as: BMJ 2011;343:d7773


  • Competing interests: None declared.

  • Provenance and peer review: Commissioned; not peer reviewed.