Symposium: ABJS/C.T. Brighton Workshop on Trauma in the Developing World

David A. Spiegel¹ 

David A. Spiegel Email: spiegeld@email.chop.edu

Received: 14 February 2008  Accepted: 8 July 2008  Published online: 26 August 2008

Injuries are a neglected epidemic in low- and middle-income countries (LMICs), accounting for 11% of the world’s disease burden in 2001, and ranking 11th in all causes for both mortality and morbidity [9]. Road traffic crashes are predicted to be the eighth leading cause of death, and the fourth leading cause of DALYs (disability adjusted life years) by 2030 [10]. Each year, many of the 20 to 50 million injury survivors are left with a permanent disability, most often related to the musculoskeletal system. The economic and social costs of injuries are profound, and undoubtedly contribute to the vicious cycle of poverty in many developing nations. Despite the weight of evidence of this huge burden, research concerning the prevention and treatment of injuries in LMICs has been underfunded, and limited resources have been allocated for strengthening the delivery of medical services for the injured, including surgical care. Providing universal access to safe, timely, and effective services for musculoskeletal injuries will require a multidisciplinary, multisectoral effort aimed at strengthening the health care system. Key stakeholders include governments and their ministries of health, orthopaedic surgeons and other health care providers (surgical, medical and nonmedical), economists, public health specialists, and various organizations (nongovernmental organizations, professional societies, academic institutions).

The workshop commenced with two outstanding keynote addresses, in which two complementary initiatives from the World Health Organization were described. Both projects emphasized the provision of universal access to a core group of “essential” services, which are efficacious, cost-effective, and must be made available to all members of a society. The Guidelines for Essential Trauma Care provides health planners with a basic template from which “essential” trauma services may be organized at different levels of health facility, in terms of infrastructure, physical resources, and human resources [11]. Once the capacity to deliver these services is developed and maintained, their quality must be assured by imparting knowledge and skills to health care providers. The Emergency and Essential Surgical Care Project focuses on strengthening the delivery of essential surgical and anesthetic services at primary health facilities through the use of an integrated training package [1, 6, 14, 15]. These initiatives highlight the recognition that the treatment of injuries is a global public health priority, and demonstrate the World Health Organization’s commitment to this aim. Estimates suggest that more than 200 million major surgical procedures are performed in the world each year, more than twice the number of annual births [16]. As patients from the poorest third of the world receive only 3.5% of these procedures, large disparities in access to basic surgical care exist between rich and poor countries, and there is an enormous unmet need for surgical services in the poorest nations [16]. While the global burden of the surgical diseases has yet to be quantified (or disaggregated from existing data sets), injuries represent a substantial portion of this burden [3]. Surgery has traditionally been viewed as costly, technologically demanding, and resource intensive, but recent evidence suggests that surgical services can play a cost effective role in population-based healthcare [2, 3, 4, 8].

The first series of papers concern country models for the delivery of musculoskeletal trauma care. The burden of trauma was emphasized, especially road traffic crashes, and common challenges were discussed. Deficiencies in the capacity to provide services include a lack of infrastructure, inadequate physical resources, insufficient numbers of healthcare providers, and a lack of organized systems for addressing the burden of trauma. Assuming that the capacity to deliver essential services can be provided, the quality of services depends upon the acquisition, maintenance, and enhancement of knowledge and skills within the health workforce.

Addressing the burden of musculoskeletal injuries at the country level begins by acknowledging that injuries are a major public health concern. While experiential evidence supports this contention, there is limited epidemiologic information on the burden of musculoskeletal injuries in LMICs. Epidemiologic data must be collected to quantify the burden, and to identify risk factors, at the local, regional, and national levels. This knowledge may not only guide preventive efforts, but also inform the allocation of resources for strengthening care for the injured. Governments and their ministries of health, as “stewards” of each health system, must be convinced to implement (and enforce) policies and legislation aimed at prevention, treatment, and rehabilitation following injuries. While providing a full complement of trauma care services is unrealistic at the population level in LMICs, a core group of services can and should be provided as “rights of the injured”, as defined by the two initiatives from the World Health Organization. Prehospital care must also be addressed. Formal systems for stabilization and transport may be impractical because of geographic barriers (lack of roads or motorized transport) and/or economic constraints, but informal mechanisms must be developed utilizing members of the community, such as the “enlightened citizen” or others (taxi drivers, truck drivers, police). Improvements in the capacity and quality of musculoskeletal trauma services, focusing on safe, low-risk, and low-cost interventions, can only be achieved through a multidisciplinary, multisectoral effort.

The next session focused on regional perspectives on training health workers, including orthopaedic surgeons. Recognizing the global crisis in the health workforce, especially in the rural areas in LMICs, only a small subset of patients with musculoskeletal injuries will ever be treated by an orthopaedic surgeon. In addition to a shortage in absolute numbers, the migration of health workers (brain drain) from rural to urban environments, and from economically underdeveloped to economically developed regions (and countries), has created large gaps in access to care. While the majority of people in LMICs reside in a rural setting, most health workers are found in urban areas. Strategies must be developed to staff the health facilities in rural or underserved areas, and to impart the appropriate knowledge and skills required to treat musculoskeletal injuries. Training programs must be geared to the local disease burden, and must focus on interventions which can realistically be provided with the resources available locally. Some countries have invested in training surgeons and surgical subspecialists, while others have embraced the concept that paraprofessionals may be adequately trained to care for selected surgical conditions, including musculoskeletal injuries. This approach has become popular in sub-Saharan Africa, and while the titles, skill set, and responsibilities of these health workers vary between countries, they often make a substantial contribution to the delivery of surgical services at district level health facilities. For example, the Orthopaedic Clinical Officers provide a large percentage of the musculoskeletal services in Malawi. Another approach involves the training of “rural” surgeons, recognizing that the “western” model of surgical education, including the training of subspecialists, does not suit the needs of rural communities in LMICs. Rural surgery has been defined as “need based multidisciplinary surgery under resource constraints to make surgical care affordable and accessible to the community” [7]. Dr. K.M. Shyamprasad has been a strong advocate for this nontraditional model of training, to address large gaps in access to surgical care in the rural areas of India. He provided the group with an excellent overview of the rationale, scope of practice (including the musculoskeletal component), and current status of the rural surgeons program in India. After completing medical school, candidates enter a three year training program focusing on a core group of procedures, emphasizing the treatment of emergencies, drawn from all of the surgical subspecialties including obstetrics/gynecology. They are then certified, and expected, to practice in a rural environment. There is now an International Federation of Rural Surgeons, and the majority of members practice in sub-Saharan Africa and India. The role of nongovernmental organizations and international orthopaedic societies in improving musculoskeletal trauma care was also explored. While some organizations provide service in the field, the importance of training cannot be overemphasized, and the greatest impact comes through sustainable educational programs. For example, Health Volunteers Oversees has promoted a model in which short term volunteers provide ongoing education in a variety of specialties, including orthopaedic surgery. Short-term educational courses in trauma care may also be beneficial, as illustrated in Ghana and Lesotho. Training traditional bonesetters may also be productive, as a short course in fracture care was shown to decrease the incidence of complications such as infection and gangrene [12]. These practitioners care for a large number of patients with musculoskeletal injuries in LMICs, and working with them, rather than against them, can only benefit the health care system.

Even if adequate staffing with health workers can be achieved, mechanisms to maintain and enhance their education must be developed. While continuing medical education may be provided through courses, workshops, and professional interactions, health workers also need immediate access to relevant and reliable information, appropriate to the problems they treat, using the resources available to them. The internet provides access to a voluminous amount of information, but is this a practical resource for the busy health worker in a LMIC? Many international journals present high quality scientific publications, but the content may not reflect the disease burden in LMICs, and the methods of treatment may not be applicable at the district hospital level in LMICs. While local or regional journals from LMICs may contain more relevant information, most are not indexed in Medline or other databases. Initiatives such as the Ptolemy project may help bridge the gap, providing individuals and institutions with access to not only journals, but also a variety of other educational resources. In addition, there is an urgent need for research studies concerning the many facets of musculoskeletal trauma in LMICs. Relevant topics include the epidemiology/prevention, development of appropriate and sustainable treatment (and training) strategies for the resource-constrained environment, and mechanisms to address the burden at the level of the health system.

In addition to formal presentations, the workshop included a number of breakout sessions, in which small groups were charged with discussing an issue and presenting their recommendations to the general session. Topics included the delivery of prehospital and hospital-based musculoskeletal trauma care, teaching and training of orthopaedists and nonorthopaedists, and methods to improve collaboration with other stakeholders to improve musculoskeletal trauma care in LMICs. A synopsis of most of these sessions is included in this symposium.

In conclusion, musculoskeletal injuries are a substantial burden in LMICs; the problem is complex, multidimensional, and can only be solved through a multidisciplinary, multisectoral effort. The ABJS/CT Brighton workshop generated considerable enthusiasm among participants, and we all hope this will translate into collaboration in the future. While we recognize the importance of prevention, improving treatment is essential. Best practice guidelines will necessarily vary between (and within) countries, yet the overall goal must be to strengthen both capacity and quality at the level of the health system. This may be accomplished by providing adequate infrastructure, essential physical resources and supplies, training (and ongoing education) for both the orthopaedist and the nonorthopaedist, and access to appropriate medical information. The time has come for the global orthopaedic community, in association with other stakeholders, to address the many barriers to the delivery of safe, timely, and effective care for patients with musculoskeletal injuries in LMICs.

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