To the Editor,

We greatly appreciate the concerns expressed by Hendel et al.1 in their recent letter addressing the World Health Organization-World Federation of Societies of Anesthesia (WHO-WFSA) standards of the safe conduct of anesthesia.2 As surgeons, we strongly support the WHO-WFSA guidelines as a critical step towards strengthening surgical systems3; more importantly, we support the efforts of anesthesiologists that are needed to make these guidelines come to life. While acknowledging the authors’ concerns, we would like to offer a slightly different perspective in two regards.

First, the authors state that anesthesiologists are not significantly engaged in National Surgical, Obstetric, and Anesthesia Plan (NSOAP) efforts. Our perspective, having observed several such processes, is that anesthesiologists (and obstetricians) have been viewed as equal partners and collaborators. Global leaders in anesthesia, with the WFSA (which has official relationsFootnote 1 with WHO), spearhead meetings, lead data collection, and frequently communicate about joint efforts. Further, the WHO Emergency and Essential Surgery Programme has always welcomed anesthesia collaboration and has hosted anesthesia interns. In March of 2018, WHO and the Harvard Program in Global Surgery and Social Change co-hosted an NSOAP regional workshop in Dubai, which included significant representation from WFSA.4

More importantly, however, the NSOAP process has no “owner” per se—all those interested are welcome. All NSOAP resources are open access and publicly available,5 including a soon-to-be published NSOAP development manual from WHO. Addressing the inequities in surgery, obstetrics, and anesthesia access will require an “all hands-on deck” approach; WHA resolution 68.15 (Strengthening Emergency and Essential Surgical Care and Anaesthesia as a Component of Universal Health Coverage)6 cannot be realized without the full and equal involvement of the anesthesia community.

Second, the authors expressed concerns that these guidelines are unrealistic for low- and middle-income countries (LMICs). While it is true that some countries cannot immediately meet the WHO-WFSA standards, national health leaders must have clear targets to structure reforms against which to measure progress. The authors’ criticisms—that aspirational goals are nice but unrealistic—could be made about several important efforts, including Disease Control Priorities, Third Edition,7 the Lancet Commission on Global Surgery,8WHA resolution 68.15,6 or the entire roster of Sustainable Development Goals.9

Such a critique as Hendel et al. espouse1 risks marginalizing the value of life in LMICs. All people deserve quality surgical, obstetric, and anesthesia care—framed around standards, guidelines and indicators—as components of universal health coverage, which by its very nature is an aspirational goal. We acknowledge that this requires a dramatic, if not unprecedented, scaling-up of “staff, stuff, space, and systems” to meet quality expectations. Together, in solidarity with our anesthesia colleagues, we need to vow to challenge the “soft bigotry of low expectations”10 in global surgery and anesthesia.