Millions of people are left dead or disabled by surgical complications each year when one simple piece of kit could have saved them. For Mosaic , Jane Feinmann discovers how it has helped transform medicine in Mongolia. Her story is republished here under a Creative Commons license.

Gundegmaa Tumurbaatar glimpsed her son only for an instant as he was carried into the aging Soviet-built hospital where she works. It was one of the first fine days after the grueling Mongolian winter, and she had left Gunbileg, aged three, and his older brother playing outside, telling them to be careful. Now, he was moaning in pain and covered from head to toe in filth and blood. A passer-by had brought Gunbileg to the hospital after seeing the two boys trying to jump over an open manhole above a sewer—watching in horror as the younger boy had fallen into the jagged pit on his abdomen. By the time Gundegmaa saw him, he was in shock, his belly frighteningly distended, an internal hemorrhage putting him at imminent risk of cardiac arrest.

She learned the details of his injuries later: his spleen, the delicate fist-sized organ that sits just below the ribs and which acts as a blood filter as part of the immune system, was ruptured. “His tummy must have caught on something sharp inside the hole in the ground,” she says. But she didn’t need to be told how serious this was. As soon as she saw him, Gundegmaa, a midwife at the hospital, knew that this was a potentially fatal internal injury. Suddenly, the life she and her husband, Batsaikhan Batzorig, had created with such effort looked about to turn to dust.

Started in the ’70s, spreading today

Gundegmaa and Batsaikhan were both born in the small town of Ondorkhaan in Khentii Province—one of the coldest spots on the Mongolian Steppe and 330 km of often deeply pitted road away from the capital city, Ulaanbaatar. They had married soon after leaving school, and their first child was born 12 years ago.

Back then it was a grim time in Mongolia, which was still in the grip of the desperate poverty that hit when 70 years of Soviet influence ended in the early 1990s. Russian forces had withdrawn from the country, taking with them the loans that had kept Mongolia afloat. It was fortunate that there were, and still are, hundreds of thousands of nomads in the country, around a quarter of the population. With their livestock—25 million cows, horses, sheep, and goats—at least people didn’t go hungry.

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But the couple worked hard to build a life together. First, Gundegmaa enrolled at the nursing school in Ulaanbaatar that had been established under the Soviet ‘Semashko’ healthcare system. Her husband remained at home with their baby—and then three years later they swapped roles 'round, so that by 2010 both had jobs with the local hospital. He was a senior nurse; she was a midwife.

Their hometown was also on a roll, it being the capital of the province where the 12th-century Mongol warrior Chinggis Khan (known as Genghis Khan elsewhere) is thought to have been born. During the Soviet era, Mongolians were forbidden even to utter the name of the man they now regard as their national hero. But in 2013, the town known as Ondorkhaan was grandly renamed Chinggis City by an act of parliament. Gundegmaa and her family could visit a new museum featuring a replica of the great leader’s ger, the traditional tent made of white felt, of this nomadic people. The town’s playgrounds, as throughout Mongolia, have figures of children (of both sexes) engaged in the ‘three manly sports’—horse riding, wrestling, and archery—that Chinggis Khan considered essential daily activities for his warriors.

Just two weeks before Gunbileg’s accident, the family had moved into their first proper home, a flat in one of the new high-rise blocks.

On duty the day of the accident was Dr Mendbayar Lkhamsuren, an experienced surgeon with more than 4,200 operations under his belt since he started working at the hospital in 2000—including, crucially, four previous cases involving a ruptured spleen. Through his training in safe surgery, Mendbayar has a genuine humility about the work he undertakes. “When I wake up in the morning, I reflect on the fact that I’m only human and that I’m just as capable of making mistakes as anyone else,” he tells me.

Mendbayar and his surgical team worked fast to remove the spleen and stem the bleeding, and Gunbileg survived. Now aged four, he needs to have all his jabs: without his spleen, he’s at increased risk of infectious diseases such as pneumonia and flu. But he is brimming with health and optimism and has a passionate attachment to “my doctor Mende.” When I meet him in the antenatal department of the hospital, keeping close to his mother, he lifts up his long white jacket, just like his hero’s, which covers a prominent scar on his tummy.

A major contributory factor to his survival is a very bright idea that is changing emergency healthcare for people living in low- and middle-income countries.

As Gunbileg was carried into the emergency room in May last year, a nurse placed on his finger a small peg-like device attached by a wire to a battered-looking yellow monitor the size of a mobile phone. “Don’t be taken in by appearances,” the hospital’s anesthetist says as she sees me squinting to inspect it during my visit last October. “That device has been used every single day for the past four years. It’s saved hundreds of lives. And it’s still going strong.”

The device is a pulse oximeter. Invented by Japanese scientists in the early 1970s, this non-invasive device, which attaches via a clip to the top of the patient’s finger, accurately measures blood oxygen saturation—the percentage of hemoglobin in the blood that is oxygenated—and displays the figure on the monitor along with the patient’s pulse rate. The device’s audible beep reassures the team that all is well, with the pitch dropping if there’s a problem, allowing the anesthetist to ‘hear’ any changes in oxygen saturation levels.

In high-income countries today, pulse oximeters are part of the furniture in recovery rooms, ambulances, accident and emergency departments, and many hospital wards—wherever patients’ symptoms are serious and unpredictable. Its most important role, however, remains where it first began: in the operating theatre. “Oximetry is a key component in the revolution in anesthesia care that has brought down the death rate from anesthesia by over 95 percent in a generation,” says Dr Atul Gawande, the Boston surgeon, bestselling author, and New Yorker magazine writer. In the early 1970s, one in 10,000 people per anesthetic administered died while under the gas in the USA: thousands of people were dying every year. By the 1990s, when pulse oximetry was routinely used, that was closer to the current figure of less than one in 100,000.

Yet the benefits of pulse oximetry have failed to spread throughout the world. More than 77,000 operating theatres in low- and middle-income countries were carrying out surgery without a pulse oximeter according to a survey carried out in 2010, two decades after pulse oximetry became routine in affluent countries.

Meanwhile, the rate of surgery in these countries has been increasing. The annual number of operations globally increased from 234 million in 2004 to an estimated 359 million in 2012 according to the World Health Organization (WHO), which reported that the 38 percent increase in ‘surgical volume’ is occurring almost exclusively in low- and very-low-resource countries. And rightly so, says Gawande. “Of course this rate of surgery is needed,” he says. “More people die every year from conditions that can be effectively treated with surgery than from HIV, malaria, and tuberculosis combined. And surgery is essential for reducing maternal mortality and deaths from road traffic accidents.”

The problem is that while the rate of surgery is increasing, so is the rate of those damaged by surgery. Research published in the Lancet in 2009 shows that more than 7 million people are left dead or disabled from complications due to unsafe surgery every year—with the risk of complications and deaths from essential operations up to 1,000 times higher in low-resource settings.

All but the newest recruits to the Mongolian anesthesia community understand the background to these statistics. Dr. Unurzaya Lkhagvajav, a former president of the Mongolian Society of Anesthesiologists, qualified as an anesthetist in 1980 and reckons she has provided anesthesia for 30,000 operations. The equipment she had available to keep a patient safe during most of these operations was a stethoscope, a watch with a second hand, and a pencil. “The only way to know if a patient’s blood was oxygenated was to take the patient’s pulse throughout the operation and check the colour of the fingernails: if they were pink, the patient was in good health,” she recalls. “It was exhausting work. And once the operation was over, the need to monitor blood oxygen levels is just as important. The only way to check for post-surgical complications was to sit with the patient all night. And of course that wasn’t always possible, not when you had a long shift the next day.”

In 2008 Gawande, at the request of the WHO, led a group of expert nurses, anesthetists, and surgeons to create the Surgical Safety Checklist. Essentially, it is a communications framework designed to eliminate human error in the operating theatre in the same way as the aviation industry has made flying safe for passengers. But alongside behavioural change to ensure effective teamwork and, for instance, that appropriate bloods and equipment are easily accessible and antibiotics administered, there’s a single piece of the kit, the pulse oximeter, that is mandated by the checklist. Without it, the WHO decided, surgery is simply unsafe.

In 2011, with the support of prominent medical institutions, Gawande helped to found the charity Lifebox to make safe surgery a reality throughout the world. “We started by doing work that reduced the cost of robust, hospital-grade pulse oximeters for low-income countries by over 80 percent to just $250,” he explains. The Lifebox oximeter can withstand extreme heat and cold, and the battery is functional for at least 12 hours. Crucially, it is also tough and can be dropped from table height without breaking. “It’s not going to break down soon after arrival, a serious problem with medical equipment in low-resource countries,” says Gawande.

Studies suggest that the WHO checklist, when used correctly with pulse oximetry, reduces complications and mortality by 30 percent. By providing pulse oximeters in low-resource settings, Lifebox estimates that it has contributed to making surgery safer for 10 million patients. Through donations, Lifebox has distributed nearly 15,000 oximeters to hospitals in settings where even the cheapest and most fragile oximeter is unaffordable. But it’s much more than this, Gawande says. “If all we were doing was parachuting in a bunch of pulse oximeters, we wouldn’t have such a tremendous impact.” Instead, through a volunteer network of anesthetists from high-income countries, Lifebox has supplied thousands of anesthesia providers in low-income countries with safety skills training. “Once you introduce the device and safety training into the riskiest part of the hospital system, you begin to build confidence that there are professional values at work aimed at generating better, safer care,” Gawande explains. “It gives clinicians confidence that they can take on more difficult cases. And people begin to believe that turning to hospitals when you are in desperate trouble is safe, that these are places you want to go.”