Charles Mock

The Global Burden of Musculoskeletal Injuries: Challenges and Solutions

Musculoskeletal injuries are a major public health problem globally, contributing a large burden of disability and suffering. This burden could be considerably lowered by implementation of affordable and sustainable strategies to strengthen orthopaedic trauma care, especially in low- and middle-income countries. This article summarizes the global burden of musculoskeletal injuries and provides several examples of successful programs that have improved care of injuries in health facilities in low- and middle-income countries. Finally, it discusses WHO efforts to build on the country experiences and to make progress in lowering the burden of musculoskeletal injuries globally.

Increasing access to surgical services in sub-saharan Africa: priorities for national and international agencies recommended by the Bellagio Essential Surgery Group.

In this Policy Forum, the Bellagio Essential Surgery Group, which was formed to advocate for increased access to surgery in Africa, recommends four priority areas for national and international agencies to target in order to address the surgical burden of disease in sub-Saharan Africa.

Developing Priorities for Addressing Surgical Conditions Globally: Furthering the Link Between Surgery and Public Health Policy

BackgroundEfforts to promote wider access to surgical services globally would be aided by developing consensus among clinicians, the public health policy community, and other stakeholders as to which surgical conditions warrant the most focused attention and investment. This would add value to other, ongoing efforts, especially in helping to define unmet need and effective coverage.MethodsIn this concept paper, we introduce preliminary ideas on how priorities for surgical care could be better defined, especially as regards the interface between the surgical and public health worlds. Factors that would come into play in this process include the public health burden of the condition and the successfulness and feasibility of the procedures to treat those conditions.Results and conclusionsThe implications of the prioritization process are that those conditions with the highest public health burden and that have procedures that are highly successful and feasible to promote globally, including in the most resource-constrained environments, should be the main focus of national and international efforts.

Establishing the Evidence Base for Trauma Quality Improvement: A Collaborative WHO-IATSIC Review

BackgroundQuality improvement (QI) programs are an integral part of well-developed trauma systems. However, they have not been extensively implemented globally. To promote greater use of effective QI programs, the World Health Organization (WHO) and the International Association for Trauma Surgery and Intensive Care (IATSIC) have been collaboratively developing the upcoming Guidelines for Trauma Quality Improvement Programmes. As part of the development of this publication and to satisfy global demands for WHO guidelines to be evidence based, we conducted a thorough literature search on the effectiveness of trauma QI programs.MethodsThe review was based on a PubMed search of all articles reporting an outcome from a trauma QI program.ResultsThirty-six articles were identified that reported results of evaluations of a trauma QI program or in which the trauma QI program was integrally related to identification and correction of specific problems. Thirteen of these articles reported on mortality as their main outcome; 12 reported on changes in morbidity (infection rates, complications), patient satisfaction, costs, or other outcomes of tangible patient benefit; and 11 reported on changes in process of care. Thirty articles addressed hospital-based care; four system-wide care; and two prehospital care. Thirty-four articles reported an improvement in the outcome assessed; two reported no change; and none reported worsening of the outcome. Five articles also reported cost savings.ConclusionsTrauma QI programs are consistently shown to improve the process of care, decrease mortality, and decrease costs. Further efforts to promote trauma QI globally are warranted. These findings support the further development and promulgation of the WHO-IATSIC Guidelines for Trauma QI Programmes.

Child injuries and violence: the new challenge for child health

Injuries and violence are a significant and growing cause of child death and disability, as well as having other health consequences including mental health, behavioural and reproductive health problems. Every year injuries and violence kill approximately 875 000 children (aged less than 18 years of age) and injure or disable tens of millions more. Injury-related causes account for 3 of the top 15 killers of children aged 0–4 years and for 6 of the top 15 killers of children aged 5–14 years. Child maltreatment has been associated with significantly increased risk of alcoholism, drug abuse, depression, suicide attempt, smoking and sexually transmitted disease. The burden from child injury is most felt in low- and middle-income countries, where 95% of all child-injury deaths occur, and where recorded rates of child maltreatment are substantially higher than in high-income countries. This huge public health problem is all that much more tragic because it is avoidable. Through combinations of prevention and care, most high-income countries have considerably reduced rates of child-injury death and child maltreatment. Consequently, there are huge inequities globally, with annual child-injury mortality of 8.6/100 000 in high-income countries compared with 41.8/100 000 in low- and middle-income countries.1 In other words, rates of child-injury death are more than four times higher in low- and middle-income countries. A large burden of death and morbidity could be avoided by bringing violence and injury rates in low- and middle-income countries down to levels similar to those in high-income countries. Such public health benefits could be achieved by use of proven prevention methods, such as implementing and enforcing safety legislation and standards; promoting home and transport safety; modifying products or the environment; and improving care and rehabilitation of injured children. Programmes to promote safe, sustainable and nurturing relationships between children and their parents or caregivers can substantially reduce child maltreatment, and youth violence prevention programmes can significantly reduce violence-related death and injury in adolescents. These strategies, most of which are affordable and sustainable in all countries, need to be better applied globally. Child injury and violence need to be better incorporated into broader child survival strategies. Child injury and violence have been only minimally addressed thus far by the global health community and by most governments. Likewise, these topics have been inadequately addressed in the scientific literature. An upcoming theme issue of the Bulletin (May 2009) on child injury and violence will seek to address these shortcomings, to promote greater attention to these significant public health problems, to promote greater uptake of known effective prevention and treatment interventions globally, and to stimulate more research on low-cost and sustainable ways to confront these problems especially in low- and middle-income countries where most children live. The Bulletin theme issue will examine the spectrum of child injury and violence prevention and control including epidemiology, prevention, care and rehabilitation. It will contain papers in the categories of Perspectives, Policy and practice, Research, and Lessons from the field. Several papers will be commissioned. In addition, submissions from interested authors are highly encouraged. We welcome papers for all sections of the Bulletin that focus on any of the following topics: surveillance and data collection; evaluation of methods to prevent unintentional injury and violence; health systems strengthening or financing for child injury and violence prevention interventions; or methods for strengthening emergency care and/or rehabilitation of injured and maltreated children. We would especially encourage papers that go beyond the health perspective to address the cross-sectoral nature of the problem. For example, papers on transport safety could encompass the multi-sectoral nature of road traffic injury, including human behaviour, roadway infrastructure and vehicle design, and broader issues of urban design. Papers on violence could include coverage of the multi-dimensional determinants of violence, including parenting, childhood exposures and subsequent health and social consequences, and societal-level factors such as socio-economic disparities. Likewise, papers examining responses to violence could discuss actions involving the educational, welfare and criminal justice sectors, as well as the health sector. Papers discussing how child injury and violence issues can be better addressed in the broader child survival and global health agendas are encouraged. These could include discussions of the relationship of child injury and violence and Millennium Development Goals such as Goal 4 (reducing child mortality). Papers from authors in developing countries are especially encouraged. It is hoped that the papers in this issue will contribute important information that will assist public health practitioners, clinicians, researchers and policy-makers to better confront the eminently preventable problem of child injury and violence. The deadline for submissions is 1 September 2008. Manuscripts should be submitted to: http://submit.bwho.org respecting the Guidelines for Contributors and accompanied by a cover letter mentioning this call for papers. All submissions will go through the Bulletin’s peer review process. ■

The Political Economy of Emergency and Essential Surgery in Global Health

Emergency and essential surgery (EES) remains a low priority on global health agendas even though a growing body of evidence demonstrates that EES is a cost-effective public health intervention and that it holds the potential to prevent a sizable number of deaths and disabilities. The inferior status of EES should be considered, in part, a political problem and subject to political analysis. This type of political economy examination has been used for other important global health issues but has not been applied to EES. By addressing political concerns and prospects, EES can be better positioned on international agendas, thus improving surgical care delivered to the poor.

Strengthening care of injured children globally

Part of the solution to the growing problem of child injury is to strengthen the care that injured children receive. This paper will point out the potential health gains to be made by doing this and will then review recent advances in the care of injured children in individual institutions and countries. It will discuss how these individual efforts have been aided by increased international attention to trauma care. Although there are no major, well-funded global programmes to improve trauma care, recent guidance documents developed by WHO and a broad network of collaborators have stimulated increased global attention to improving planning and resources for trauma care. This has in turn led to increased attention to strengthening trauma care capabilities in countries, including needs assessments and implementation of WHO recommendations in national policy. Most of these global efforts, however, have not yet specifically addressed children. Given the special needs of the injured child and the high burden of injury-related death and disability among children, clearly greater emphasis on childhood trauma care is needed. Trauma care needs assessments being conducted in a growing number of countries need to focus more on capabilities for care of injured children. Trauma care policy development needs to better encompass childhood trauma care. More broadly, the growing network of individuals and groups collaborating to strengthen trauma care globally needs to engage a broader range of stakeholders who will focus on and champion the improvement of care for injured children.

Strengthening Prehospital Trauma Care in the Absence of Formal Emergency Medical Services

The article by Jayaraman, Mbweijano, Lipnick et al. represents an important contribution to the literature because it addresses one of the most significant and difficult issues in care of the injured [1]. This is the issue of how to improve prehospital trauma care services in areas of lowand middle-income countries that are beyond the reach of any formal emergency medical services (EMS). This issue is of great significance for several reasons: Most of the injured who die do so in the field, before there is any chance of hospital care. In lowand middle-income countries the proportion of prehospital deaths is much higher than in high-income countries. For example, one study showed that of all trauma patients who die, 81% die in the field in a low-income setting (Ghana) compared with 72% in a middle-income setting (Mexico), and 59% in a highincome setting (USA). This difference in prehospital deaths is a major contributor to the overall higher case fatality rates for severely injured persons in lowand middleincome countries. Furthermore, it has been roughly estimated that some 50–75% of the world’s people live in areas with no access to formal EMS [2, 3]. In brief, this paper is of great relevance to the field of trauma care, as it addresses the situation in which many— possibly most—fatal injuries occur: in the field, in a lowor middle-income country, in an area with no formal EMS. This scenario has scarcely been addressed by the field of trauma care research, thus far. Given these factors, the question then arises of how to improve access to prehospital trauma care in the setting of lowand middle-income countries, especially in areas where no formal EMS currently exists. The World Health Organisation (WHO) publication Prehospital Trauma Care Systems gives guidance on two complementary approaches, designated tier 1 and tier 2 care. Tier 1 implies care by first responders, often not as part of a formal system, whereas tier 2 implies formal EMS, such as with an ambulance service [4]. There is evidence from several locations worldwide that each approach may be useful, depending on the circumstances. One study from Brazil has documented the effects of a new ambulance service (i.e., tier 2) started where none had previously existed: The mortality rate among victims of motor vehicle crashes decreased from 7.1% (before) to 5.9% (after) [5]. However, starting new formal EMS should be approached with caution, given the potential high cost. An economic analysis from Kuala Lumpur, Malaysia, suggested that upgrading that city’s existing basic EMS to a high-income model would cost

What World Health Assembly Resolution 60.22 Means to Those Who Care for the Injured

2.5 million per year, with only an additional 7 lives per year saved [6]. Whether one agrees with the specifics of this economic analysis or not, certainly the caution these authors urge is warranted. Hence, there is a need not only to consider the creation of new formal EMS, but also alternatives that will increase local access to basic first aid measures (i.e., tier 1 care). In some cases these might be considered as adjuncts to formal EMS, allowing ambulance services to extend their reach through networks of first responders. In other cases, these might be standalone efforts, especially in circumstances where formal EMS would be impractical or too costly. Often, these efforts to increase access to basic first aid The author is a staff member of the World Health Organization. He alone is responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization.

Barriles de absorción y contención del impacto: reducción de mortalidad por accidentes de tránsito

On May 23, 2007, the World Health Assembly (WHA) adopted WHA Resolution 60.22, “Health Systems: Emergency Care Systems,” which called on the World Health Organization (WHO) and governments to adopt a variety of measures to strengthen trauma and emergency care services worldwide. This resolution constituted some of the highest level attention ever devoted to trauma care worldwide. This article reviews the background of this resolution and discusses how it can be of use to surgeons, emergency physicians, and others who care for the injured, especially in low- and middle-income countries.