Reader response

Myron Yaster MD

From Ralph Epstein, DDS, Clinical Associate Professor, Chief, Division of Dental Anesthesiology, Program Director, Dental Anesthesiology Residency Program
Stony Brook Medicine

I am writing this email to let you know how much I enjoyed your PAAD of June 30 here. I have been a program director for the accredited Dental Anesthesiology Program at Stony Brook Medicine for over 18 years and have trained over 60 dental anesthesiology residents. I totally share your thoughts about working with residents who can’t understand how those of us who trained before 1985 treated thousands of patients without automatic NIBP monitors, pulse oximetry and gas analysis. I also share your thoughts about the use of EEG monitoring and the benefits it holds for patient care. Because a great majority of my patients are developmentally and/or intellectually disabled I find the use of EEG monitoring irreplaceable. When using BIS or SedLine my ID/DD patients have fewer hypotensive events and wake up in a predictable way without delayed awakening or untoward side effects such as PONV. I find these same wakeups with dementia patients whether they have a diagnosis of Alzheimer’s or Pick’s disease.

From Matt Kynes MD, AIC Kijabe Hospital, Kenya, Vanderbilt University Medical Center, USA

I am always grateful for the historical perspective here. The advances in anesthetic care have been astounding, but it is worth noting that they have not been evenly distributed. In fact, there still exist places where pediatric anesthetic care looks more like it did in 1876 than it does in 2026! Mortality for common procedures in older children in the 19^th century was 26-50%, which has dropped by 100-250x in high-income countries but only 10-20x in low-income countries. For neonatal surgery, mortality in low-income countries remains 40-90% for congenital GI anomalies and >50% for emergency GI surgery (Global PaedSurg Research Collaboration: Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study. Lancet (London, England). 2021;398(10297):325–39. Epub 20210713. doi: 10.1016/s0140-6736(21)00767),only a modest improvement from the near 100% mortality for these conditions in 1876. In 1876, access to safe and timely pediatric surgery would have been extremely rare. In 2026, >97% of children in low-income countries and >92% of children in lower-middle income counties still lack this access (Bull World Health Organ. 2019; 97: 254-258).

Although there are many contributors these persistent disparities, limited workforce and equipment are two of the most significant. The lack of workforce in resource-constrained settings is illustrated by a version of the 80/20 rule in surgery — 80% of the global noncommunicable disease mortality occurs in low- and middle-income countries, where only 20% of the global surgical workforce resides. Kwinji and colleagues (Pediatr Anesth. 2022;32:372–379) presented a review of the realities of pediatric anesthesia equipment in the resource-constrained setting. They describe the lack of appropriate ventilators, monitors or endotracheal tubes means that anesthetists in many of these settings opt for ketamine and local anesthetic infiltration with a spontaneously breathing patient, an approach not too dissimilar to anesthetic practice decades ago.

For those who would like to help bring anesthetic care everywhere up to the present, there are good opportunities available. The Pediatric Anesthesia Training for Africa (PATA) program is starting and sustaining pediatric anesthesia fellowships in Uganda, Zambia, Nigeria, and Ethiopia and donations can be made here https://wfsahq.org/our-work/education-training/fellowship-programme/paediatric-anaesthesia-training-in-africa-pata/. LifeBox, which has been featured in PAAD many times, is still making huge strides in bringing pulse oximetry and now capnography to places of need and contributions can be made here https://donate.lifebox.org/campaign/703970/donate. Please consider making a contribution today.

From Quentin A. Fisher, MD, FAAP

Thank you so much Mark and Janet for sharing this through your PAAD here. I
thoroughly enjoyed your providing such a compelling perspective on a what was a remarkable 4 decades of medical advance. Attention to detail inluded pointing out that Agnew, only a few years after Gross, had the advantage of an electric lightbulb to illuminate the surgery! I believe the period from 1970 to 2000 (in which we trained) was also quite remarkable - in which the ability to measure physiologic change in real
time developed with continuous ECG, oximetry, end-tidal gas analysis, invasive monitoring (including cardiac output and contractility), bedside Echo etc... helped move clinical anesthesia from an art to a science.

From Myron Yaster MD and Nancy Finnel

More on America’s Changing Causes of Death: Lessons from 250 Years of Medical Progress

https://health.yahoo.com/conditions/cancer/articles/killed-americans-1776-answer-dramatically-110038988.html

This article examines the remarkable transformation in the leading causes of death in the United States since 1776, illustrating how advances in public health, preventive medicine, and clinical care have more than doubled life expectancy. At the time of the American Revolution, life expectancy was approximately 35–40 years, although this figure largely reflected extraordinarily high infant, childhood, and maternal mortality rather than universally short adult lifespans. Today, average U.S. life expectancy approaches 79 years, representing one of the greatest achievements of modern medicine and public health.

During the eighteenth century, infectious diseases dominated mortality. Pneumonia, smallpox, measles, diphtheria, dysentery, scarlet fever, tuberculosis, cholera, and typhoid fever were frequent causes of death because effective treatments and preventive measures did not exist. Childbirth was also associated with substantial maternal mortality owing to the absence of antibiotics, blood transfusions, antiseptic techniques, and modern obstetric care. Consequently, reductions in infectious disease and maternal mortality became the principal drivers of improved longevity over the following two centuries.

The article highlights several landmark public health interventions responsible for these improvements. Development of municipal water systems, sewer infrastructure, indoor plumbing, and improved sanitation during the nineteenth century dramatically reduced waterborne infectious diseases. Acceptance of germ theory transformed understanding of disease transmission and supported implementation of quarantine measures, food safety legislation, and hygiene practices. By 1900, these advances had increased average life expectancy to approximately 49 years.

Vaccination and antibiotics produced the next major leap in survival. Beginning with Jenner’s smallpox vaccine in 1796 and followed by Pasteur’s vaccines for rabies and anthrax, immunization expanded throughout the twentieth century to include protection against polio, measles, mumps, rubella, and influenza. Likewise, the widespread introduction of penicillin and other antibiotics during the 1940s transformed previously fatal bacterial infections into treatable illnesses. By 1950, life expectancy had increased to approximately 68 years.

Subsequent gains resulted from advances in chronic disease prevention and treatment. Improved management of hypertension, cardiovascular disease, diabetes, and cancer substantially reduced mortality among older adults. Public health initiatives promoting smoking cessation, safer motor vehicles, improved trauma care, and advances in emergency medicine further contributed to increasing survival. These developments shifted the primary causes of death away from infectious diseases toward chronic, age-related illnesses.

Despite these successes, the article emphasizes that contemporary challenges differ substantially from those faced in earlier centuries. Modern medicine now focuses less on preventing premature death from infection and more on preserving healthy aging. Between 2014 and the COVID-19 pandemic, gains in life expectancy slowed because of opioid overdoses, alcohol-related mortality, suicides, and other preventable deaths. Obesity, particularly childhood obesity, remains a growing contributor to cardiovascular disease, diabetes, and cancer. The increasing incidence of early-onset colorectal and breast cancers among younger adults further highlights the importance of lifestyle modification and preventive screening.

The central message is that many of the greatest improvements in human longevity resulted from public health interventions rather than therapeutic advances alone. Clean water, sanitation, immunization, antibiotics, nutrition, and preventive medicine collectively transformed survival. Looking forward, experts suggest that the next frontier is not simply extending lifespan but extending healthspan through prevention of chronic disease, healthier lifestyles, equitable access to healthcare, and continued advances in cardiovascular and cancer care. These lessons underscore the enduring importance of integrating public health strategies with modern clinical medicine to improve population health.

From Anonymous

Another look at private equity take over of medical practices from Dr. Glaucomflecken