The history of surgery goes back to prehistoric times, but the history of Lifebox begins more recently. Founded in 2011 by four of the world’s leading medical professional organizations, it is the only charity devoted to safer surgery and anaesthesia in low-resource countries.
In the last five years our equipment and education programme, proven to reduce the risk of surgical complications and mortality by over 40%, has set the standard for appropriate technology and global distribution in challenging settings.
We’ve made surgery safer for 10 million patients worldwide through improving anaesthesia safety, building new networks across professional, academic and commercial organizations – from cutting-edge research institutions to rural heath centres in more than 100 countries. We’re prioritising the most invisible, essential component of any complex system: safety.
Because fundamentally, Lifebox is about saving lives.
From a bold idea to a streamlined organisation with a powerful voice for global surgery, here’s how we began.
In 2007 the World Health Organization (WHO) recognised a new global health crisis creeping up the mortality charts. This killer wasn’t a virus or an unknown plague: it was unsafe surgery.
Road traffic accidents; childhood trauma; maternal mortality; more than 234 million operations take place each year, and millions more are needed to fight an epidemic of avoidable pain and disability. Surgery is the sharp line between life and death, livelihood and dependency, civil society and alienation, and WHO’s decision affirmed what anyone who ever had an operation knows: surgery isn’t a luxury.
But safe perioperative care is.
In 1999, hospital errors reportedly killed 100,000 people a year in the US, and surgery in low-resource settings was estimated to be up to a thousand times more dangerous.
Lack of appropriate equipment and training meant that millions of life-saving operations were actually causing harm. Healthcare workers lost patients who should have been saved and returned the next day knowing nothing would be better. Families were forced to choose between unsafe surgery and no surgery at all.
Something had to change, and around the world, future Lifebox colleagues agreed.
Working in Zambia in the 1980s, Association of Anaesthetists of Great Britain and Ireland (AAGBI) president Dr Iain Wilson had seen patients die on the operating table, slipping in to cardiac arrest from undiagnosed lack of oxygen. Universal access to pulse oximetry – a monitor that clips onto the finger and sounds an alarm at the slightest change in a patient’s oxygen level – would prevent this horror.
But even in the new millennium pulse oximeters remained absent from tens of thousands of operating rooms worldwide (later estimated to be 77,000). Inappropriate machines, poor distribution networks, lack of resources and training contributed to an anaesthesia mortality risk as high as 1 in 133 in West Africa.
In 2004 the AAGBI and the World Federation of Societies of Anaesthesiologists (WFSA), two of Lifebox’s co-founders, launched a multi-country trial to test the feasibility of global pulse oximetry. Their findings showed the equipment could work successfully in a low-resource setting and that education had an essential role to play – paving the way for the thousands of oximeters that would follow.
Safety revolutions don’t make the same headlines as political change, but they hold the fate of millions. When airlines introduced pilot checklists, failure rates fell so dramatically that defying gravity became one of the safest ways to travel.
Surely the same was possible for surgery: a system we invented but with the best human will in the world, consistently let down.
Pauline Philip, the Director of Patient Safety at WHO, now the Lifebox Vice Chair, saw an opportunity. She invited a young endocrine surgeon, Atul Gawande, to join the search for a practical solution. The New Yorker staff writer, New York Times bestseller and Lifebox founder admitted in his 2009 hit about the process, The Checklist Manifesto that she “didn’t take no for an answer.” He led experts from all operating room disciplines – nurses, anaesthetists, surgeons – in a bid to do for surgical patients what airlines had done for passengers.
And so the WHO Surgical Safety Checklist was born: a communications framework to eliminate error from a high-risk sphere. A pilot study across eight countries, poor and wealthy, proved that this A4 piece of paper was a wonder drug in disguise. And all it took was commitment to good communication – and a pulse oximeter.
But which one? 40-70% of medical devices in low-resource settings were estimated to be regularly out of service. Giant storerooms blighted hospitals, ‘equipment graveyards’ full of inappropriate, ineffectual machines. The Lifebox oximeter was not going to join them. Rather than asking manufacturers what devices were available, it was time to tell them what was needed.
A global tender for the ideal low-resource setting pulse oximeter got underway, led first by WHO and then by the WFSA. Rechargeable batteries so that patients stayed monitored during frequent power cuts; robust enough to survive falls from the operating room table; intuitive and low-maintenance for an environment with limited biomedical engineering: the oximeter selected by Lifebox’s founders met all these essential features, at a price that would make direct purchase feasible for the first time – and with an education programme that would ensure effective, long-term use.
The Checklist was the framework and the oximeter was the tangible item, safety in the hand: together they would make surgical safety a global right, not a privilege. And Lifebox was the organization that would help to make it happen.
Founded in 2011 by the WFSA, AAGBI, the Brigham and Women’s Hospital, and the Harvard T. H. Chan School of Public Health, Lifebox has four key areas of work: equipment, basic safety checks, education and sustainability.
Over the last four years, we’ve developed a distribution system that combines modern logistics with a timeless approach to building relationships. We’ve developed a system to identify where the need for equipment and training sits, and how we can work with local communities to help them develop safer practice long-term.
With a small staff spread across the world, we’ve facilitated distribution of more than 13,000 pulse oximeters to 100 countries worldwide. We’ve introduced the Surgical Safety Checklist at our initial pilot site hospital in Rwanda and beyond, and education materials to spread it worldwide. We’re expanding our work into prevention of surgical site infection, another major cause of avoidable surgical mortality.
The global health landscape is changing. For the first time in history, you’re more likely to be killed by a surgically-treatable condition than a communicable disease. Unsafe perioperative care is the new global health crisis, and Lifebox is on the frontline. Our team is committed to developing networks, relationships and trust with our partners – building a global fellowship that will deliver sustainable change.
We know we can’t do it alone. Lifebox works with procurement experts, with NGOs, with membership networks and individual doctors around the world who are committed to making surgery safer. We’ve galvanized hundreds of thousands of dollars in support – money, yes, but also time, skills, platforms and voices that will no longer let the global surgical safety crisis maim and kill millions quietly.
There’s a long way to go. But we also know that we’re making a difference – and that our work is meeting a vital and growing need.
Recently we heard from a nurse anaesthetist in Ethiopia.
“When you come to my profession, pulse oximetry is the heartbeat for my work, for safe surgery,” she explained. “But I couldn’t ever say – ‘we have no monitor’ and refuse to work. I had no choice but to save life as best I can. Now thanks to Lifebox, we are using the oximeter and the World Health Organization Surgical Safety Checklist in our hospital. I would like to thank you again and again for your life-saving activity. You are not only supporting patients, you are also helping professionals.”
Since 2011, not a day goes by without an oximeter in transit – by plane, by boat, on the back of a moped – from our manufacturer in Taiwan to the most rural medical centres around the world. We’re working with colleagues on the ground to plan new workshops; to follow up those that have taken place. Each one is making a difference to healthcare workers and to thousands of patients. And we’re just getting started.