Should Low- and Middle-Income Countries Invest in Developing
Prehospital Trauma Care Systems?
By Jason Friesen, MPH, EMT-P
BACKGROUND: THE GLOBAL BURDEN OF ROAD TRAFFIC INJURIES
In a 2005 report by the World Health Organization (WHO), injury was described as “one of the leading causes of mortality and morbidity worldwide.” More specifically, road traffic injuries were identified as the second leading cause of death worldwide for people aged 5-14 years, the leading cause of death for those aged 15-29 years, and the third leading cause for people aged 30-44 years. What is particularly concerning about these statistics is the fact the 15-44 year-old age group also represents the most economically productive age group of any society. Coupled with other categories, such as self-inflicted injuries, interpersonal violence, sexual violence, burns, drowning, and poisonings, among others, WHO estimated that injury is responsible for approximately 5.8 million deaths each year, which is approximately 10% of all deaths worldwide, and “32% more than the number of fatalities that result from malaria, tuberculosis, and HIV/AIDS combined.”
In light of expanding globalization – including increased motorization, industrialization, and rapid economic growth – it can be reasonably expected that the incidence of road traffic injuries will likewise increase. In 1996, WHO projected that injuries would be the first or second leading cause of healthy years of life lost worldwide by 2020 – an increase of 109% from 1990, surpassed only by cancer – and the fifth leading cause of death for all ages combined by 2030.
The consequences of these increases have the potential to overwhelm low- and middle-income countries (LMICs) in particular. As it stands now, in the case of road traffic injuries, which account for one quarter of all injury-related deaths, LMICs suffer over 90% of the word’s road fatalities while owning less than 50% of the world’s registered vehicles. Furthermore, the majority of road traffic injury victims are not vehicle drivers, but rather pedestrians and vehicle passengers, implying a vulnerability to traffic-related injuries regardless of ownership. A clearer example of this disparity can be found in India, which has “1% of the motor vehicles in the world, but bears the burden of 6% of the global vehicular accidents.”
Nonetheless, the effects of injury go beyond fatalities alone; after all, not every injury results in death. Both temporary and permanent disability can have equally significant consequences on individuals, families, and their communities – loss of income due to disability can extend beyond the victim when family members have to leave work to stay at home and provide care for the victim, as well as subsequent losses in productivity within the local work force. Injuries can also have significant financial impacts on the local health care system. To better illustrate this, consider the “Injury Pyramid” which is often referred to by epidemiologists when discussing the demands that are placed on the health sector by injury victims (Figure 1). As depicted, it is assumed that injury victims will inevitably seek some sort of medical attention, regardless of the causative mechanism – whether it is for acute complications resulting from the injury, or chronic problems resulting from a lack of medical attention immediately following the incident; or if it is from injuries resulting in hospitalization, treatment at another health care facility, or treatment outside of the health care system. Despite the type or degree of injury, the healthcare system will be negatively affected, whether directly or indirectly. Further compounding the problem is the fact that the poor are often unable to make a full recovery due to a lack of adequate rehabilitation services.
Governments must also deal with the financial impacts that injuries have upon their economies. While global estimates of the financial burden of injury are scant, Roy et al. have summarized the existing research by reporting that “injury burden and mortality is inversely proportional to a country’s per capita gross national product.” In more specific terms, a WHO study recently estimated the global cost of road traffic accidents at US$518 billion per year, generally costing countries between 1-2% of their gross domestic product (GDP), though rising to 5% in India, Malawai and Viet Nam. At a more local level, Mock et al. reported that in a Ghanaian region of just over a million population, 68% of disabled persons had reported declined income resulting from an injury or consequent disability, and 40% “indicated that the family’s food consumption had declined” as a result thereof.
Clearly, road traffic injuries are a significant concern in today’s rapidly globalizing world, particularly for LMICs whose economies are already facing significant developmental obstacles. At the same time, the inadequately-funded health systems of LMICs can hardly afford to both invest in and sustain the human and physical resources that characterize modern trauma and emergency care systems in high-income countries (HICs), despite their well-documented effectiveness.[1,11,12] Fortunately, alternatives to these resource-heavy trauma care systems exist for resource-constrained countries. This paper describes such alternatives and argues that LMICs can significantly mitigate the societal and financial impacts of preventable death and permanent disability by developing basic, low-cost and high-impact prehospital trauma care systems.
A RBRIEF OVERVIEW OF EMERGENCY MEDICAL SERVICES IN WEALTHY COUNTRIES
The advent of the modern U.S. EMS system can be broadly summarized by the convergence of two separate, yet equally influential events in the development of modern emergency medicine. The first was the formalization of cardiopulmonary resuscitation (CPR) as a medical intervention that could be taught to laypersons, coupled with the invention of the portable cardiac defibrillator. The second development, and perhaps more influential from an organizational perspective, was the 1966 publication of “Accidental Death and Disability: The Neglected Disease of Modern Society” by the National Academy of Sciences (NAS). The “White Paper”, as it is commonly referred to, addressed what NAS described as the “magnitude of the problem of accidental death and injury” in the U.S., and produced a list with recommendations for the fifteen essential components to be included in the development of local EMS systems. Soon thereafter, state governments, public health, and public safety departments – assisted by significant federal funding – were involved in planning, developing and implementing these systems to address the devastation caused by road traffic accidents.
Since those formative years, EMS systems have become an integral part of both public health and safety efforts across the U.S. Though prehospital medical care is certainly not an American “invention” per se, the U.S. is widely recognized as among the first countries to formalize the operational system as a whole. Today, formal prehospital systems that provide basic and advanced emergency medical care are present in 134 of 178 countries. However, the definition of a “formal system” is open to debate, and the percentage of the world’s population that has actual access to these systems has been estimated at less than half.
Generally speaking, formal EMS systems can be classified into two system models: Anglo-American or Franco-German. In the Anglo-American model, the underlying philosophy is to “bring the patient to the doctor,” which is carried out by “physician surrogates” – non-physician practitioners trained in basic and advanced emergency medical interventions – who treat patients in the field and then transport them to an emergency department for stabilization, where they are either discharged or admitted to a specialty ward within the hospital.[14,16,17] This model is commonly found in the U.S., the U.K., Canada and Australia. In contrast, the philosophy behind the Franco-German model is to “bring the doctor to the patient.” In this model, it is predominately physicians and nurses that treat and stabilize patients in the prehospital setting, and then either release or admit them directly to a specialty ward within the hospital.[16,17] This model is commonly found in France, Germany, Portugal and Brazil.
While many variations may exist within each model type, there are two certainties that they both share: advanced EMS systems are highly expensive to develop, implement and sustain[18,19]; and the advantages of advanced life support (ALS) over basic life support (BLS) interventions for trauma victims is not certain.[17,20,21] Nonetheless, many LMICs have attempted, or at least have considered creating their own advanced system. Typically, the results are dubious at best. In a 1997 study to determine the costs and benefits of implementing an ALS EMS system in Kuala Lumpur, Malaysia, Hauswald et al. reported a “conservative” cost estimate of US$2.5 million per year that “might save seven lives, three marred by significant neurological damage.” Though this type of study was one of the first of its kind, and therefore subject to debate, the results are no less significant – ALS systems are far too expensive for LMICs with substantial resource constraints.[1,14,16,20] And, regarding the efficacy of ALS systems for trauma patients in any country, Liberman et al. concluded in 2008 that “there is no convincing evidence that prehospital ALS in the urban setting provides any benefit to injured patients in terms of either morbidity or mortality.” Therefore, in LMICs primarily focused on treating injury victims, the majority of ALS trauma interventions – including oro-/naso-tracheal intubation, needle thoracostomy, needle and surgical cricothyroidotomy – should largely be avoided when developing prehospital trauma care systems in resource-constrained settings.
In contrast, BLS interventions for trauma victims – including basic airway management maneuvers, manual ventilation, hemorrhage control and spinal stabilization – have long been shown to effectively reduce preventable deaths, mitigate disabilities, and improve overall injury morbidity and mortality rates.[4,20,23,24] BLS trauma supplies are also comparatively inexpensive, and can often be produced using simple everyday items.[1,25] Based on these analyses, there is increasing evidence supporting the development of BLS prehospital trauma care systems in LMICs to help alleviate the growing burden of road traffic injuries that they increasing struggle with.
RE-ASSESSING EMERGENCY CARE NEEDS IN LMICs
At the time that NAS published The White Paper, road traffic accidents were “the leading cause [of death] for all age groups under 75” among all accidental deaths in the U.S. In many ways, the situation that the U.S. faced in the mid-1960s is very similar to what LMICs are experiencing today: increased motorization, coupled with a lack of proper road planning, traffic regulation and trauma care systems, is resulting in road traffic accident mortality rates that can easily be described as an “epidemic”.
It is important to note that the development of prehospital trauma care systems alone will not decrease overall morbidity and mortality rates – other initiatives, such as public education and awareness programs, injury prevention programs, better road planning practices and improved in-hospital trauma capabilities undoubtedly play an important role in reversing these trends.[1,7,12,26,27] However, by implementing basic, low-cost and high-impact systems, LMICs can start making significant headway by providing care in the prehospital setting where approximately 80% of all injury-related deaths occur. Despite myriad differences in cultural, political and healthcare considerations among LMICs, in the author’s opinion the most promising way to develop effective systems in resource-poor countries includes: adapting the Anglo-American model of non-physician emergency responders by utilizing layperson responders; training these responders in BLS trauma interventions to treat life-threatening injuries; and coordinating local vehicle drivers (e.g., taxis, commercial vehicles, police cars, rickshaws) to provide rapid transportation to appropriate medical facilities for definitive care. Similar to the “Neighborhood Crime Watch” associations common in American communities, prehospital trauma care systems based on these tenets will provide the early access, immediate life-saving medical interventions, and expedited transport that are the hallmarks of efficacious EMS systems in HICs.
OBSTACLES FOR PREHOSPITAL TRAUMA CARE SYSTEMS IN LMICs
While a sizeable body of literature exists documenting early evidence of the effectiveness of BLS prehospital trauma care systems in LMICs, the research and experiences describing these initial successes invariably offer similar acknowledgments of the inherent difficulties and obstacles in designing and implementing systems that meet essential requirements. These requirements include, first and foremost, that public services are accessible to all members of the targeted population, regardless of the ability to pay – victims and their families should not have to choose between financial ruin and death or disability. It is also essential that the system sets goals that are achievable, culturally appropriate, legal, and, most importantly, both affordable and sustainable.
Critics of developing EMS capabilities in LMICs often argue that limited available resources should be focused on bolstering primary care and existing health services, pointing out that efforts to implement EMS systems in resource-poor countries comparable to those in HICs, while well-intentioned, would be a waste of resources and money, not to mention logistically impossible[1,23] – particularly if these systems result in decreased funding for existing health services. However, the resistance against providing funds for prehospital trauma care systems can often be attributed to a lack of awareness of the magnitude of the problem, the importance of such services (and their low-cost alternatives to EMS systems in HICs), and the long-term benefits derived from providing them. While many injury-related deaths in the prehospital setting are undoubtedly instantaneous[1,24] – and therefore not amenable to medical interventions – an equally significant proportion of these deaths would certainly be preventable with basic prehospital trauma care,[1,16,23,24] thus mitigating the impacts of road traffic injuries. As Mock and colleagues concluded in 1998, “as a nation develops economically, the highest yield in reducing trauma deaths is likely to come from improvements in the emergency medical system.” Prehospital trauma care systems, therefore, must play an integral part in any community’s emergency medical system, as hospital-based care cannot be provided until patients arrive. And when care is not provided in the field, hospital-based efforts to save lives and/or limbs often prove futile,[1,11,13,16,23,24] further wasting otherwise limited resources and supplies.
As mentioned, the development of any prehospital system must provide access to its intended constituency, but it must also do so effectively. For example, urban centers in developing countries are often comprised of narrow streets, rough terrain and insurmountable traffic congestion, making the notion of dispatching ambulances to and from the scene of an emergency within an effective timeframe more fantasy than reality.[30,31] This is especially concerning when considering the importance of minimizing response and transport times for polytrauma victims. A popular and effective solution to these problems has involved the training of taxi drivers and law enforcement personnel to provide basic trauma care, as these professional groups regularly encounter road traffic accidents and are also able to transport injured patients to a hospital rapidly.[32,33] Likewise, these specific vehicles are typically equipped with radio communications; in the absence of the costly communications and dispatch centers common in HICs, utilizing existing telecommunications infrastructure will facilitate early notification of motor vehicle injury victims (and their location) to lay-responders, and thus enable expedited response times in order to provide immediate, life-saving interventions.
Prehospital trauma care systems must also set goals that address the specific needs of the target population and ensure that these goals are achievable. In northern Iran, along the Iraqi border, the holy pilgrimages of Iranian Shia take them through rural areas that are also minefields, resulting in a high incidence of blast injuries, road traffic accidents and assaults. The lack of adequate physical, financial, and human resources, the rural landscape, and the intermittent nature of the pilgrimage, makes the implementation of a formal EMS system in this area logistically unrealistic. However, by enhancing the existing rural healthcare system’s infrastructure and trauma capabilities with low-cost improvements, and by introducing layperson BLS trauma training, studies of such programs in rural areas of Northern Iraq have provided evidence of significant improvements in injury mortality and morbidity rates.[34,35] Similar programs with equally promising potential have been replicated in Ghana, Uganda, Cambodia, and Eastern Europe. These efforts, including several others under the auspices of WHO’s Essential Trauma Care program, have provided additional evidence that simple, low-cost training can provide basic, effective access to trauma care by improving and enhancing limited existing resources through innovative means.[37,38] In short, the highly expensive vehicles, equipment and medical technology that are commonplace in advanced EMS systems are not essential to providing life-saving prehospital care.
Not surprisingly, there are also cultural implications to be considered when looking to provide prehospital services to populations that are not accustomed to accessing them. In India, efforts to implement ambulance services have been hampered by the public’s lack of education regarding what an ambulance is for and how to access one – many mistakenly identify ambulances as hearses, reserved for transporting only the dead. In many other developing countries, like Indonesia, it is common to find that the population subscribes to a fatalistic view of road traffic-related deaths, regarding them more as the result of destiny than as a public health and safety problem that is amenable to prevention and mitigation. Dixey, who studied the attitudes toward road traffic accidents and other injuries among the Yoruba population in Nigeria reported that “predestination [provides] one explanation for misfortune, including accidents and a reason not to take precautions.” These same attitudes – ascribing accidents to the supernatural or the result of random acts of destiny – were equally prevalent in the U.S. and other developed countries only a few decades ago.[7,13] But just as this thinking was changed in developed countries through education, so too will it have to change in LMICs. As Pitt et al. pointed out, if this (fatalistic) viewpoint dominates “there is often no real impetus to improve the state of prehospital emergency care.” Furthermore, by improving education and awareness, additional efforts to enhance road safety and further reduce accidents can be initiated, including: increased traffic regulation and enforcement; drink-drive and helmet laws; better road planning; and injury prevention programs such as seatbelt use and car seats for children.
PREHOSPITAL CARE SYSTEMS AND GOVERNMENT
The successful design and implementation of any prehospital trauma care system will also be influenced by the legislative implications of organizing hese services. In their seminal work, Prehospital Trauma Care Systems, WHO subject matter experts pointed out that “legislation and regulation help to ensure public health and safety, ensure that the expectations and legal authority of each agency and individual are clearly delineated, and promote a consistent level of care and systems response throughout the nation.” Without the involvement of government bodies, and their ability to legislate a structural framework to support prehospital systems and practitioners, efforts to develop an effective system that ensures the continued commitment of key stakeholders will be difficult to sustain.
Legislative support is also important to ensure that the system can operate as intended. In North Viet Nam, Medical Teams International, a U.S.-based non-governmental organization, was involved in training laypersons in basic life-saving skills, which included the use of stethoscopes. However, according to local laws, only licensed physicians were permitted to use this type of medical equipment. This presented a significant obstacle, as the effectiveness of lay-responder care would have been severely inhibited without stethoscopes. Notwithstanding many difficulties, successful efforts were eventually achieved to change the law and thus ensure continuance of the program. While the intricacies and nuances of governmental attitudes and policies on prehospital care are beyond the scope of this paper, the involvement of governments and legislative support cannot be understated, especially when considering funding.
Because LMICs, by definition, are lacking substantial tax and payer bases to support such medical services – especially in the case of privately-run models – alternative solutions are needed. This has proven to be challenging; Doney et al. have identified EMS development as one of the most difficult healthcare initiatives to fund, and prehospital trauma care funding has historically received minimal attention from developmental organizations. For these reasons, WHO correctly observes that “it may be necessary to make reasonable efforts to recover costs in order to ensure the financial viability of the service, and various financing schemes may be needed to fund the system, such as health insurance or public funding.” Existing alternatives may include: government budget appropriations; corporate social responsibility programs; philanthropic grants; cross-subsidy models; community-based loan funds; third-party insurance schemes; enacting nominal increases in public transportation fees; “dedicating a proportion of highway construction budgets; allocating a proportion of vehicle registration fees, traffic fines and penalties; or levying a tax on fuel.” Whatever strategy is implemented to generate funding, it must be appropriate to the local economic conditions and, above all, must ensure consistency if the system hopes to gain credibility and build support among its target population and other key partnerships.
In LMICs, the problems presented by death and permanent disability resulting from road traffic injuries have been neglected for too long. And, as globalization continues to spread, these problems will certainly follow closely behind. However, just as the U.S. addressed these same issues in the mid-1960s by implementing robust EMS and hospital-based trauma systems, so too must LMICs seek an effective response to this growing epidemic to ensure that their societal and economic aspirations are not further hindered.
While prehospital trauma care systems in the resource-constrained settings of LMICs should not be replicated upon the resource-heavy and costly systems in HICs, basic, low-cost and high-impact alternatives can have an equally significant impact. At a minimum, these alternative systems should be comprised of layperson responders trained in basic, life-saving trauma care, and supported by the integration of existing transportation systems that utilize pre-installed telecommunication capabilities. These components are ideal for resource-constrained settings because they are both effective and low-cost. In fact, other than the training component, the majority of these systems already exist, however informal. The goal is to organize, enhance and improve existing infrastructure for maximum efficacy with minimal financial impact. As for training, BLS trauma care is similarly ideal: it needs minimal physical or financial resources to implement; it can be taught in very little time with impressive retention rates; and it requires virtually no prerequisites in regards to prior education levels or even literacy.
Finally, by implementing basic prehospital trauma care systems, additional important healthcare services will also have a foundation from which to build. These added services could include additional training in emergency childbirth (supported by existing transport schemes), thus helping to reduce the high maternal- and infant-mortality rates that are also prevalent in many LMICs, by providing access to trained healthcare professionals as well as transportation to proper medical facilities. Other possibilities involve the expansion of lay-responder training to include more advanced prehospital cardiovascular and neurological care. This type of program has already shown success in Kurdistan, Northern Iraq. Prehospital care systems also help to lay the framework for developing disaster response capabilities by training personnel in mass-casualty management and by improving community preparedness. Yet perhaps most underappreciated is the public health monitoring capabilities inherent to these systems – providers acting as the “eyes and ears” of the community, collecting and relaying front-line, eyewitness evidence of newly emerging health trends and safety risks. Despite the wealth of proven public health improvements that prehospital systems can effectively provide through inexpensive means, LMICs – and the international health community at large – must recognize that by continuing to neglect the development of prehospital trauma care systems to address the problems posed by road traffic injuries, they are neglecting the development of the entire country.
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