Opinion: Trauma health care would save lives in lower-income countries

A nurse treats the shoulder injury of a patient at a hospital in Hinche, Haiti. Photo by: Sgt. Tony Hawkins / U.S. Army / CC BY-SA

Injury makes up 10% of the global burden of disease, with 90% of this burden falling on low- and middle-income countries, according to the World Health Organization. Globally, road traffic injuries are the leading cause of death for people ages 15-29 and the third most common cause in the 30-44 age group.

These young people make up a significant proportion of the workforce and are the largest contributors to the economy. The devastating financial impact of sustaining an injury on the injured and their families is most evident in low- and middle-income countries, where a larger proportion of the population lives below the poverty threshold.

A single traumatic injury can lead to food insecurity and an inability to fund a child’s education, creating a cycle of impoverishment. In sub-Saharan Africa, “48% of people in the region would be driven into financial catastrophe if they needed surgery.” The fear of these costs is often the greatest deterrent to accessing hospital care, and the consequence of that legitimate fear may be chronic disability.

Those who do seek and reach care may not receive it until they have paid. Patients may have to wait for days, or weeks before receiving definitive care, given the time it may take for their family to raise the required funds to buy essential materials, and, often, surgical supplies. In the meantime, the advantage that early intervention offers is lost — the patient's condition worsens, and the situation rapidly turns to a matter of life or death.

A patient who has sustained massive blood loss requires blood for a chance at survival. But obtaining blood products in LMICs can be challenging. This is just one example that demonstrates the fragility of trauma care delivery and the need for trauma system development.

In Haiti, for instance, we are working on a trauma system strengthening project, called PROjet Trauma HAïti, or PROTHA. We selected four hospitals in three of the country's largest cities — two of the hospitals are training centers for specialists. The project leaders are Haitian surgeons and emergency care physicians working with trauma systems surgeon researchers at Harvard.

Without adequate pre-hospital care infrastructure, patients with life-threatening injuries often die before they can reach the hospital.

Implementation of a triage system, trauma care and skills training, adapted trauma registry, and other changes collectively serve to improve the quality of trauma care. The study’s long-term impact relies heavily on it being conducted by local researchers and clinicians. Crucially, when local practitioners set the study agenda, the real needs are addressed, and the impact more likely to benefit the community.

In the U.S. and other high-income countries, many of us take for granted that if injured, we can call a free number and an ambulance with trained emergency care providers will arrive. Yet in many LMICs, hospital transport services do not exist, and the injured person must arrange their own transport or rely on the generosity of good Samaritans.

In Haiti, a medical transport system does exist: The National Ambulance Center provides transport for emergencies. But the service is slow to arrive on the scene, covering mainly urban areas, and transport providers who lack emergency care training. More commonly, patients are transported by residents, relatives, or volunteers, by various means ranging from makeshift stretchers to motorcycles.

Without adequate pre-hospital care infrastructure, patients with life-threatening injuries often die before they can reach the hospital. The risk of dying from trauma has been shown to decrease by 25% in areas of LMICs with pre-hospital trauma systems.

The complexity of implementing a trauma system requires a targeted evaluation process that includes six key areas: infrastructure, workforce, service delivery, information management, finance, and leadership/government. These are the building blocks of national surgical, obstetric, and anesthesia plans, of which trauma is recognized as a fundamental component.

These plans have been prioritized by member states of WHO’s western Pacific region and by members of the Southern African Development Community, such as Zambia and Tanzania, with the sole priority of improving care within these domains. For the first time, the U.S. Agency for International Development has been specifically instructed that grant monies may be used to fund trauma systems development.

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The ultimate goal of strengthening trauma systems is to reduce preventable deaths and trauma-related morbidity. The fact that trauma systems save lives is not a supposition — chances of surviving trauma increased to 20% after implementation of major trauma networks in the U.K., and that the risk of mortality among U.S. trauma patients is 20% less among those sent to the top designation of trauma center. Yet these systems are not accessible to the majority of the world’s population.

No one is immune from trauma. There are clear disparities in the U.S., with lower socioeconomic status, non-white race, Hispanic ethnicity, and rurality associated with decreased access to trauma care, and older age a clear factor in trauma mortality. Still, 85% of people in the U.S. can reach well-equipped trauma centers within a single hour. This is not the reality for much of the world. Trauma will kill almost 6 million people this year, and leave many millions more with devastating injuries.

The views in this opinion piece do not necessarily reflect Devex's editorial views.

About the authors

  • Sylvio Augustin

    Sylvio Augustin, MD, is a general surgeon at the State University of Haiti and on the board of the Haitian Association of Surgeons. He works on the PROjet Trauma Haïti (PROTHA).
  • Gabrielle Cahill

    Gabrielle Cahill, MPH, works at the Program in Global Surgery and Social Change at Harvard Medical School, where she focuses on trauma systems development and strengthening in low- and middle-income countries. She works on the PROjet Trauma Haïti (PROTHA).
  • Michelle Joseph

    Michelle Joseph, MD Ph.D., orthopedic trauma surgeon, works at the Program in Global Surgery and Social Change at Harvard Medical School, where she focuses on trauma systems development and strengthening in low- and middle-income countries. She works on the PROjet Trauma Haïti (PROTHA).