Olive Kobusingye

Emergency medical systems in low- and middle-income countries: recommendations for action

Emergency medical care is not a luxury for rich countries or rich individuals in poor countries. This paper makes the point that emergency care can make an important contribution to reducing avoidable death and disability in low- and middle-income countries. But emergency care needs to be planned well and supported at all levels--at the national, provincial and community levels--and take into account the entire spectrum of care, from the occurrence of an acute medical event in the community to the provision of appropriate care at the hospital. The mix of personnel, materials, and health-system infrastructure can be tailored to optimize the provision of emergency care in settings with different levels of resource availability. The misconception that emergency care cannot be cost effective in low-income settings is demonstrably inaccurate. Emergencies occur everywhere, and each day they consume resources regardless of whether there are systems capable of achieving good outcomes. With better planning, the ongoing costs of emergency care can result in better outcomes and better cost-effectiveness. Every country and community can and should provide emergency care regardless of their place in the ratings of developmental indices. We make the case for universal access to emergency care and lay out a research agenda to fill the gaps in knowledge in emergency care.

Injury patterns in rural and urban Uganda

Objectives—To describe and contrast injury patterns in rural and urban Uganda. Settings—One rural and one urban community in Uganda. Methods—Community health workers interviewed adult respondents in households selected by multistage sampling, using a standardized questionnaire. Results—In the rural setting, 1673 households, with 7427 persons, were surveyed. Injuries had an annual mortality rate of 92/100 000 persons, and disabilities a prevalence proportion of 0.7%. In the urban setting 2322 households, with 10 982 people, were surveyed. Injuries had an annual mortality rate of 217/100 000, and injury disabilities a prevalence proportion of 2.8%. The total incidence of fatal, disabling, and recovered injuries was 116/1000/year. Leading causes of death were drowning in the rural setting, and road traffic in the city. Conclusion—Injuries are a substantial burden in Uganda, with much higher rates than those in most Western countries. The urban population is at a higher risk than the rural population, and the patterns of injury differ. Interventions to control injuries should be a priority in Uganda.

Citywide trauma experience in Kampala, Uganda: a call for intervention

Objectives: To describe injuries and their emergency care at five city hospitals. Setting: Data were collected between January and December 1998 from casualty departments of the five largest hospitals of Kampala city, Uganda, with bed capacity ranging from 60 to 1200. Methods: Registry forms were completed on trauma patients. All patients with injuries were eligible. Outcome at two weeks was determined for admitted patients. Results: Of the 4359 injury patients, 73% were males. Their mean age was 24.2 years, range 0.1–89, and a 5–95 centile of 5–50 years. Patients with injuries were 7% of all patients seen. Traffic crashes caused 50% of injuries, and were the leading cause for patients ≥10 years. Fifty eight per cent of injuries occurred on the road, 29% at home, and 4% in a public building. Falls, assaults, and burns were the main causes in homes. Fourteen per cent of injuries were intentional. Injuries were severe in 24% as determined with the Kampala trauma score. One third of patients were admitted; two thirds arrived at the hospital within 30 minutes of injury, and 92% were attended within 20 minutes of arrival. Conclusions: Injuries in Kampala are an important public health problem, predominantly in young adult males, mostly due to traffic. The majority of injuries are unintentional. Hospital response is rapid, but the majority of injuries are minor. Without pre-hospital care, it is likely that patients with serious injuries die before they access care. Preventive measures and a pre-hospital emergency service are urgently needed.

The Burden of Road Traffic Injuries in Nigeria: Results of a Population-Based Survey

Background: Mortality from road traffic injuries in sub-Saharan Africa is among the highest in the world, yet data from the region are sparse. To date, no multi-site population-based survey on road traffic injuries has been reported from Nigeria, the most populated country in Africa. Objective: To explore the epidemiology of road traffic injury in Nigeria and provide data on the populations affected and risk factors for road traffic injury. Design: Data from a population-based survey using two-stage stratified cluster sampling. Subjects/setting: Road traffic injury status and demographic information were collected on 3082 respondents living in 553 households in seven of Nigeria’s 37 states. Main outcome measures: Incidence rates were estimated with confidence intervals based on a Poisson distribution; Poisson regression analysis was used to calculate relative risks for associated factors. Results: The overall road traffic injury rate was 41 per 1000 population (95% CI 34 to 49), and mortality from road traffic injuries was 1.6 per 1000 population (95% CI 0.5 to 3.8). Motorcycle crashes accounted for 54% of all road traffic injuries. The road traffic injury rates found for rural and urban respondents were not significantly different. Increased risk of injury was associated with male gender among those aged 18–44 years, with a relative risk of 2.96 when compared with women in the same age range (95% CI 1.72 to 5.09, p<0.001). Conclusions: The road traffic injury rates found in this survey highlight a neglected public health problem in Nigeria. Simple extrapolations from this survey suggest that over 4 million people may be injured and as many as 200 000 potentially killed as the result of road traffic crashes annually in Nigeria. Appropriate interventions in both the health and transport sectors are needed to address this significant cause of morbidity and mortality in Nigeria.

Human resources for the control of road traffic injury

The definition of the ideal numbers and distribution of human resources required for control of road traffic injury (RTI) is not as advanced as for other health problems. We can nonetheless identify functions that need to be addressed across the spectrum of injury control: surveillance; road safety (including infrastructure, vehicle design, and behaviour); and trauma care. Many low-cost strategies to improve these functions in low- or middle-income countries can be identified. For all these strategies, there is need for adequate institutional capacity, including funding, legal authority, and human resources. Several categories of human resources need to be developed: epidemiologists who can handle injury data, design surveillance systems, and undertake research; engineers and planners versed in safety aspects of road design, traffic flow, urban planning, and vehicle design; police and lawyers who understand the health impact of traffic law; clinicians who can develop cost-effective improvements in the entire system of trauma treatment; media experts to undertake effective behaviour change and social marketing; and economists to assist with cost-effectiveness evaluations. RTI control can be strengthened by enhancing such training in these disciplines, as well as encouraging retention of those who have the needed skills. Mechanisms to enhance collaboration between these different fields need to be promoted. Finally, the burden of RTI is borne disproportionately by the poor; in addition to technical issues, more profound equity issues must be addressed. This mandates that people from all professional backgrounds who work for RTI control should develop skills in advocacy and politics.

Epidemiology of injuries presenting to the national hospital in Kampala, Uganda: implications for research and policy

BackgroundDespite the growing burden of injuries in LMICs, there are still limited primary epidemiologic data to guide health policy and health system development. Understanding the epidemiology of injury in developing countries can help identify risk factors for injury and target interventions for prevention and treatment to decrease disability and mortality.AimTo estimate the epidemiology of the injury seen in patients presenting to the government hospital in Kampala, the capital city of Uganda.MethodsA secondary analysis of a prospectively collected database collected by the Injury Control Centre-Uganda at the Mulago National Referral Hospital, Kampala, Uganda, 2004-2005.ResultsFrom 1 August 2004 to 12 August 2005, a total of 3,750 injury-related visits were recorded; a final sample of 3,481 records were analyzed. The majority of patients (62%) were treated in the casualty department and then discharged; 38% were admitted. Road traffic injuries (RTIs) were the most common causes of injury for all age groups in this sample, except for those under 5 years old, and accounted for 49% of total injuries. RTIs were also the most common cause of mortality in trauma patients. Within traffic injuries, more passengers (44%) and pedestrians (30%) were injured than drivers (27%). Other causes of trauma included blunt/penetrating injuries (25% of injuries) and falls (10%). Less than 5% of all patients arriving to the emergency department for injuries arrived by ambulance.ConclusionsRoad traffic injuries are by far the largest cause of both morbidity and mortality in Kampala. They are the most common cause of injury for all ages, except those younger than 5, and school-aged children comprise a large proportion of victims from these incidents. The integration of injury control programs with ongoing health initiatives is an urgent priority for health and development.

Strengthening trauma and critical care globally

Purpose of reviewTrauma is an increasingly significant health problem globally, especially in low-income and middle-income countries. Trauma care is often compromised by economic restrictions. Many capable individuals are attempting to meet this challenge in their own countries, however. This review summarizes such efforts and assesses how they might be expanded in a comprehensive, global fashion. Recent findingsOptions for improving trauma care in the prehospital setting have been explored, including strengthening existing, basic formal emergency medical services (including ambulances); instituting new formal emergency medical services, where none had previously existed; and exploring novel ways to strengthen existing, although informal, systems of prehospital care when formal emergency medical services would be infeasible. Affordable ways by which to strengthen hospital care have been addressed for several specific injuries, including open fractures, burns, and vascular injuries. Especially notable are growing efforts to better monitor outcomes and address factors contributing to preventable deaths. The Essential Trauma Care Project has defined and promoted core essential trauma care services that every injured person in the world realistically can and should be able to receive. This project is a collaborative effort of the World Health Organization and the International Society of Surgery. SummaryIndividual efforts must be built upon to make progress in a comprehensive, global fashion. This review summarizes the background, achievements, and future potential of the Essential Trauma Care Project and several related efforts.

A unified framework for injury control: the public health approach and Haddon's Matrix combined

Injury specialists have not successfully convinced policy makers and the public that injuries can be controlled. That failure may be due in part to the lack of a unified understanding of injury control. The two most important models utilized in injury control are Haddons Matrix1 and the Public Health Approach (PHA). This paper argues that the PHA should be combined with the two axes of Haddons Matrix to result in a model that is coherent and comprehensive. Thus it is better than either one of the original models on their own. Haddons Matrix has two axes. The first includes elements of the epidemiological triad, host, vector, and environment and likens injury to disease. The second axis includes three time intervals, pre-event, event, and post-event. The importance of including time was that injury was conceptualized as predictable and preventable. The weakness of Haddons matrix is that it lacks a systematic plan of action. The Public Health Approach is a methodology for addressing injury, which consists of a hierarchy of four levels; surveillance, risk factor identification, intervention evaluation and program implementation. The use of the PHA with no specific orientation or means of application is its weakness. The PHA lacks a systematic point of application. Haddons Matrix lacks a systematic action plan. Therefore we propose the PHA as the systematic strategy for the more theoretical framework of Haddons matrix. By combining these concepts a coherent and comprehensive three-dimensional framework is defined. The unified model closes the potential gaps in the two original models and includes a systematic approach not previously achieved. This unified model is practical in defining individual studies and groups of studies. It can be used as an inventory, for a complete understanding of a particular injury. Diagrams of the model are presented to help teach the concepts of injury described in this unitary model. In conclusion, we can say that the inclusion of three injury concepts in one framework provides a rigorous and coherent construct for the understanding of injury and implementation of control activities. It can therefore be used to design more comprehensive programs for injury control and promote policies and funding commensurate with the magnitude of the injury problem.

Socioeconomic impact of road traffic injuries in West Africa: exploratory data from Nigeria

Background Road traffic injuries (RTIs) are increasingly contributing to the burden of disease in sub-Saharan Africa, yet little is known about the economic consequences and disability associated with them. Objective To explore cost and disability consequences of RTIs in Nigeria. Design A population-based survey using two-stage stratified cluster sampling. Subject/setting Information on care-seeking choice, cost of treatment, ability to work, reduction in earnings, and disability were collected on 127 subjects who had suffered an RTI, of 3082 study subjects in seven Nigerian states. Outcome measures Univariate analysis was used to estimate frequency of disability, types of care sought, and trends for work lost, functional ability and cost of treatment. Unadjusted bivariate analysis was performed to explore care-seeking, cost of care, and work lost among disabled and non-disabled people. Results RTIs resulted in disability for 29.1% of subjects, while 13.5% were unable to return to work. Of the disabled people, 67.6% were unable to perform activities of daily living, 16.7% consequently lost their jobs, and 88.6% had a reduction in earnings. Private physician and hospital treatment were the most common forms of initial treatment sought, but traditional treatment was the most common second form of care sought. Average direct costs of informal and formal treatment were US

Universal health coverage and intersectoral action for health: key messages from Disease Control Priorities, 3rd edition

6.65 and US