The existing art and science of Orthopaedic & Trauma Care in Nepal reflects the level of available resources for medical care in general. Being a low middle income country (LMIC), Nepal has many levels of medical care. Recent data show the mortality and morbidity due to accidents (road traffic or others) to be in epidemic proportions, resulting in significant loss of active young manpower of countries like Nepal. The high percentage of death rate due to road traffic accidents (RTAs) alone depicts the level of trauma care in our health institutions. This is attributed to the major number of the pedestrians and cyclists who are involved in the RTAs in the country where large numbers are living below poverty line.
It is also linked to the gross overcrowding of public transport and to the poor maintenance of roads and vehicles. Although density of traffic must also play a major part, it is interesting to remember that in the rich world where car ownership is much higher the incidence of fatalities on the road is decreasing. This is possibly due to better discipline amongst vehicle drivers, particularly in urban areas where traffic density is even higher than in the developing world. There is also another difference between East and West and that is the speed of the traffic, which may be terrifying at times. But there may be yet another cause for the decreasing rate of road traffic fatalities in the high income countries (HICs) and that is the increasing expertise available in major trauma centres for coping with potentially fatal trauma, combined with well-integrated ambulance services staffed by paramedics.
Trauma or injury ranks 4th in the 10 most common health problems in Nepal. Injury is a major global disease burden for the twenty-first century as it is a medical condition affecting all ages of people. As per WHO report (2009), more than 90% of the five million deaths each year due to injury occur in low- and middle-income countries, where preventive efforts are often non-existent, and health-care systems are least prepared to meet the challenge. So trauma has become the silent epidemic in the low middle income countries (LMICs) like Nepal. By 2030, according to the Global Burden of Disease Study 2014, road accidents will be the third leading cause of death in LMIC, ahead of malaria, tuberculosis and HIV. Yet, trauma only receives a tiny fraction of the attention and money given to these infectious diseases.
The application of appropriate treatment of fractures in resource constraint countries can improve outcome to high income country levels and reducing the injury-related deaths in LMICs (low middle income countries) to rates in high income countries could save 1.7 – 1.9 million lives each year.
Even after the earthquake, there was no proper management of the large number of casualties and only very few hospitals were equipped to provide disaster relief and trauma care. Nepal received a lot of teams of doctors and surgeons for trauma care from around the world but research proves that mission surgical trips cannot be more effective than specialized surgical centres. Also a strong need was felt for training the doctors in managing trauma victims during and after disasters.
Many areas in the country are still lacking basic health services due to poor economy, and ignorance and traditional beliefs often demand alternative approach of health care. Changes from traditional methods are often slow and at times require a period of integration of the new with the old.
Also in the absence of proper primary care and transportation, the patients often travel long distances, causing undue delay in obtaining proper medical treatment. Thus initial management and subsequent follow-up care becomes a prohibitive logistic problem in our country and although the infrastructure development in Nepal does not appear to be lacking, manpower training and availability of basic facilities are inadequate or inappropriate.
As the national priority of primary health care involves mainly medical measures, the concept and practice of primary surgical care has yet to be developed. To avoid unnecessary complications, effective primary care should be available at the peripheral level by an appropriately trained person. The lack of simple splinting, for example, may make simple injuries more complicated by the time the patient is brought to the hospital.
A scientifically trained general practitioner can effectively treat nearly 90% of common conditions, but until the basic requirements of adequate law and order, shelter, transport, communications, schooling, remuneration, facilities and equipments to treat common conditions are made available at the peripheral centres, all attempts to depute the trained doctors to remote and rural places will remain ineffective. On the other hand if there were adequate facilities at the periphery it could drastically reduce the number of patients with simple ailments seeking treatment in the main referral centres thus sparing the consultants there for more specialized work.
In Nepal more than 80% of the people live in the rural areas while more than 80% of the qualified doctors work in the urban sectors. Until there is improvement in the doctor patient ratio in the rural area, primary medical care will largely depend upon the locally available, economically affordable and socially acceptable traditional healers and unqualified rural practitioners. The Orthopaedic Care in Nepal ranges from commonly available traditional healers and bone-setters in the villages to the scarcely equipped hospitals in the towns. The trained Orthopaedic persons are less than one to one million populations and these are confined to the cities. Moreover, the average cost of proper Orthopaedic treatment remains too high to be affordable by the average person mainly because of little support from the existing health agencies. Sadly our popular rural health practitioners and bone-setters, who are mostly involved in the primary Orthopaedic care in the villages, usually do not have any formal education or training in this field.
A recent research on health care providers in India reveals that 60 to 80 percent of illness is treated by an ‘uncategorised’, ‘non-recognized’ and ‘outcasted’ lot of rural practitioners. The result of this study has forced the health planners to stand the modern concept of health welfare on its head and argue that these ‘non-licentiates’ be given access to confirmed status as major participants in providing front line health care to the masses. It is estimated that ten lakh rural non-licentiates are practising in rural India against three lakhs qualified MBBS doctors, 70% of whom are located in the urban areas. Therefore, it has been suggested by the Indian planners that a realistic policy of recognizing this reality and managing it in the public interest by providing the rural private practitioners training and skill could allow them to be used for first aid, first contact care, preventive and promotive works; and for illness surveillance and compliance of prolonged drug treatment etc.
Thus, it seems quite impossible, mainly due to poor economy in the LMICs, to provide effective Primary Trauma Care to a large population in the absence of adequate trained manpower and supporting facilities. The situation is further worsened by the attitudes of the concerned people to deplore the services offered by the rural traditional healers and bone-setters. There had been hardly any attempt to provide them some work training. We should make them our ally rather than our enemy. In some LMICs Orthopaedic assistants are carrying out good fracture treatment at the health centre level and possibly this service could be carried out even further into the rural community in co-operation with traditional healers, provided that basic facilities e.g. P.O.P. bandages, splints, padding etc. are readily available.
The shortage of suitably trained manpower amid lack of appropriate facilities creates a great obstacle for proper Orthopaedic care in our hospitals. On the one hand we have an extremely large number of patients needing Orthopaedic Trauma treatments while on the other hand, we are short of skilled manpower, basic operation facilities and other ancillaries. The LMICs would be ill advised to copy the system and methods of the affluent countries for they depend on high-tech systems and can cause a mental state in which our doctors and nurses think that they simply can not do anything without proper facilities, equipment and specialist team. In the poorer LMICs there is lack of all these things; and also of drugs, space, time, books, journals and informations of every kind.
Nevertheless, the two principal reasons for the misery are the pre-occupation with advanced technology and the associated inability to adapt principles to the prevailing circumstances. It appears therefore that the higher education/training in advanced world is simply not appropriate, and hence it would be far more suitable and better applicable if local doctors are trained in their own circumstances by the trainers coming from the advanced world, called Reverse Fellowship Program. In this way we can learn the art and science of adaptation and improvisation to tackle our problems more appropriately.
To improve prevention and treatment of injuries, WHO calls for capacity building in three key aspects:
- Train people with required knowledge and skills.
- Establish systems and structures to enable people to be effective.
- Strengthen capacities, set priorities and use resource effectively.
Just how big is the problem of global inequality in access to surgery? And how can we address it? In two recent publications, the Commission provides some answers.
Their findings can be summarized in five key messages.
Message 1: Nearly 5 billion people lack access to surgery
Providing healthcare to 7 billion people across the globe is hugely complex. However, healthcare really comes down to four essential components – the so-called 4S’s:
1 Staff: The doctors, nurses and administrators who treat patients and run the system.
2 Stuff: The equipment needed to do the work, from simple things like scalpels and rubber gloves to sophisticated devices like X-ray machines and hip prostheses.
3 Space: The wards, operating theaters and outpatient clinics where patients are treated.
4 Systems: The underlying structures – like access to training and proper administration – that allow the staff and equipment to work for the best outcomes of patients.
All too often, one (or more) of these elements is missing or inadequate. For example, when it comes to surgery, relatively few people actually have access to safe, affordable and timely surgical care – around 2 billion individuals in total. The remaining 5 billion – a figure based on a sophisticated modeling procedure performed by the Commission on Global Surgery – have no such access because of the absence of proper surgical centers in their area, the inability to perform a procedure safely or high costs unaffordable to the patients. What’s more, access varies widely depending on where you live. In North America and Western Europe, almost everyone has access to safe, affordable and timely surgical care; in many parts of South Asia and sub-Saharan Africa, more than 95% of people have no access at all.
Message 2: Millions more surgeries are needed in low- and middle-income countries
Of course, having no access to surgical care is only a problem when you actually need surgery. So how many people are missing out? The Commission estimates that, every year, 143 million necessary surgical procedures are not performed as a result of access failure. That adds up to hundreds of millions of people denied surgeries that could alleviate suffering, prevent disability or even save lives.
Message 3: Millions of people face catastrophic expenditure to pay for surgeries
Even when people can access surgery, the consequences can sometimes be catastrophic, for one simple reason: cost. In countries without a nationalized healthcare system or broad access to appropriate insurance, the patient has to shoulder the price of surgery. The Commission on Global Surgery has calculated that around 33 million people face financial ruin every year as a direct consequence of availing of surgical services. Another 48 million face impoverishment as a result of the non-medical costs of getting this care, such as transportation, lodging and food. Most of those at risk live in the world’s poorest countries, in sub-Saharan Africa and South and Southeast Asia.
Message 4: Urgent investment is needed
Improving surgical services in low- and middle-income countries is affordable and saves lives. It also promotes economic growth, for example, by helping those affected to get back to work. Urgent investment in the 4S’s – staff, stuff, space and systems – is required. This is where organizations like the AO Alliance Foundation can make an enormous difference. We are committed to improving the care of patients with bone fractures in low-income countries by supporting projects that will have a powerful and sustainable impact: helping patients; training healthcare workers; and empowering communities. However, we cannot change the world on our own. Our efforts must be part of a concerted international strategy to scale up global surgical access.
Message 5: Surgery is an indispensable part of healthcare
All of which brings us to the final key message, which relates to the bigger picture – the human right to health. As noted by Jim Kim, President of the World Bank: “Surgery is an indivisible, indispensable part of healthcare.” If we want a world in which everyone has equal opportunities for health, welfare and development, then access to safe and affordable surgical care is essential. And when surgical care is finally available to more people, will it make life just a little bit fairer? The answer, of course, is ‘yes’.
- Alkire BC, Raykar NP, Shrime MG, et al. Global access to surgical care: a modelling study. Lancet Glob Health 2015;3:e316-e323.
- Meara JG, Leather AJ, Hagander L, et al. Global Surgery 2030: Evidence and solutions for achieving health, welfare, and economic development. Lancet [Epub ahead of print].
Need of Trauma Care & Rehabilitation Centre
‘Trauma Center’ is an advanced health institution required for the comprehensive care of the injured persons. It also offers advanced treatment to the injured persons and suitable training to the health personnel. Nepal is the one of the four countries in the world with the highest mortality rate of more than 20% due to road traffic accidents (RTA). The principal causes of RTAs remain bad road, undisciplined traffics, worst vehicles and above all improper and inadequate ‘Medical Facilities’ available at existing health institutions in Nepal.
Therefore, a growing need has been felt since last many years to establish “Trauma Center” on a national basis and strengthen the existing hospitals to deal with the growing demand of modern care of the injured persons mainly due to growing numbers of RTAs. The high mortality and morbidity due to RTAs has been known to cause loss of active life or limb in such poor countries where human resources are always scarce. The prevalence of physical disability in Nepal has been estimated as 10% on an average and the principal cause being the various types of injuries affecting the locomotor system. It has also been felt that more than half of these physical disabilities could be prevented by proper primary trauma care of most common injuries.
However great the growth in RTAs, we must not forget that the vast majority of injuries, particularly those which are non-fatal, occur in the domestic setting of home, at place of work or in the street. In our country such type if injuries commonly occur due to fall from trees or hills.
Developments so Far
Ministry of Health (MoH) and other National/Foreign agencies like British ODA, WOC and Japanese JICA have been involved in this effort since last many years under the leadership of eminent surgeon Dr D N Gangol to establish Trauma Centre in Kathmandu and at other suitable places in the country with the main objectives that RTAs could be effectively managed at nearby centre to save life or limb within crucial time. However, there was some difference between the planning and execution mainly because of the lack of commitment to address this issue. Ex-Health Minister Dr R B Yadav established a cell in MoH as’Trauma & Disability Prevention Center’ (TDPC) and nominated Dr R K Shah, an Orthopaedic surgeon, as its “Focal Point” to study the feasibility of Trauma Center in Nepal. The TDPC worked for four years with main objective of providing primary Orthopaedic care to the patients and suitable training to the local health personnel in the peripheral hospitals. In this way the zonal hospitals at Janakpur in the East and Nepalganj in the West were adopted as pilot-centers and through these centers regular programs like Orthopaedic/Trauma Training Workshops, Orthopaedic Camps, Orthopaedic Seminar/Symposium have been organized with support from WOC-UK and IMPACT-NEPAL. As a result the Orthopaedic patients of these regions are getting proper Orthopaedic & Trauma care and the paramedical staffs of adjoining districts of these pilot-centers were trained for appropriate primary care in this field. It was also at this time that a detailed proposal of establishing a ‘National Trauma Center’ at Bardibas/Janakpur was approved by MoH and Planning Commission and it was submitted to JICA for the grant of donation. This proposal also could not be followed up because of political uncertainty in the country.
Recently the Govt. of India has built and supported to develop ‘Trauma Center’ at the National Academy of Medical Sciences (NAMS), and Bir Hospital, in Kathmandu and MoH is now gearing up to upgrade and improve this centre. However, the networking and improving trauma care in the other regions/states in Nepal remains to be developed for timely and effective care of trauma victims.
Nevertheless, the trauma centre in the capital may cause further drain of the already scarce manpower and resources from all over the country and thus regional balance and development may be seriously affected causing increased misery to the injured patients of the peripheral regions of Nepal. Thus the need of the day seems to be the development of peripheral Trauma Centers through which basic and primary Orthopaedic & Trauma Services and Training could be provided on a cost-effective manner and the apex center serves the few selected victims more effectively. This will conserve the resources and upgrade the trauma care to the most needed victims of trauma in Nepal.
The AO Foundation, the global organisation for improving the trauma care, through its Socio Economic Committee (SEC) and recently formed AO Alliance Foundation (AOAF) has been supporting various teaching and training programs in Nepal since year 2006 in the different parts of Nepal. The appropriate training and education is provided to the trauma care providers from the primary level to the tertiary level. This is the world class training for the paramedics, nurses, doctors and trauma/orthopaedic surgeons who would like to improve their knowledge and skill in fracture care of the highest standard. Till date more than 50 skill based training events have been conducted and more than 3000 health personnel have been provided highly acclaimed training courses for basic fracture care.
Local Initiative in Janakpur
Keeping the need of the country in mind, Orthopaedic & Trauma Foundation, a registered non-governmental organization working in Janakpurdham, Nepal since 1994 for reducing deformity and disability by improving the care of musculoskeletal injuries and providing training to the health personnel in Nepal is the process of establishing Janakpur Trauma Hospital (Multispeciality Trauma Care, Rehabilitation and Training Centre)
The objectives of Janakpur Trauma Hospital are :
- To provide appropriate care and services to the injured and physically disabled people.
- To reduce the mortality, morbidity and disability from injury and accidents.
- To enhance the institutional capacity of the hospital to address the existing barriers of proper care of the injured patients.
- To provide suitable training to the health personnel at all levels to improve the care of the injured people (local capacity build up).
This hospital will be the first institution in Nepal to provide appropriate care and multispeciality services to deal with orthopaedic trauma, neuro trauma, plastic trauma and maxilo-facial trauma under one roof. It will work on not-for-profit basis and provide economical service to the rich and subsidized or free service to the poor and needy people.
Conclusion & Suggestions
One of the most pressing medical issues today is how to curb the growing epidemic of RTAs as these are the third highest cause of deaths in the LMICs like Nepal and its major impact is on the poor people. Although both the facilities to reduce fatality figures are difficult to reproduce in the LMI countries like Nepal, much could be done to improve the lot of the injured who survive the journey to hospital. In our district or zonal hospitals where it is unlikely that there will be a trained Orthopaedic surgeon, the management of musculo-skeletal trauma may well be delegated to the inexperienced junior doctor or even paramedics who may have had minimal training in the treatment of fractures and soft tissues injuries. The experiences in some LMI countries in Africa has shown that trauma care can be improved dramatically by the use of specially trained clinical officers, chosen from paramedical staffs like Health Assistants and Nurses, who are not only capable of treating most simple musculo-skeletal trauma by a conservative regime, but also have the knowledge to be able to separate out the more complicated case which require referral to a specialized trauma centre. However, the methods and devices that can be used in the developed world do not necessarily work in our circumstances. Therefore, the use of simpler methods is often the more prudent course to follow, allowing conservation of the limited resources of human skill, time and materials, and to avoid worsening the situation; for what resources are available must be used in the most cost productive way. It is essential to develop a strategy based on the available resources within the existing limitations, on improvisation, and on adaptation of modern art and science of Orthopaedic surgery to the prevailing circumstances.
Improving surgical services in low- and middle-income countries (LMICs) is affordable and saves lives. It also promotes economic growth, for example, by helping those affected to get back to work. Urgent investment in the 4S’s – staff, stuff, space and systems – is required. This is where organizations like the AO Alliance Foundation can make an enormous difference. We are committed to improving the care of patients with bone fractures in low-income countries by supporting projects that will have a powerful and sustainable impact: helping patients; training healthcare workers; and empowering communities
About the Author:
Prof. Dr. Ram K. Shah, MBBS, MS, M Ch-Orth (L’Pool)
Head of Department, Orthopaedic & Trauma Surgery
Nepal Medical College Teaching Hospital, Jorpati, Kathmandu, Nepal
Regional Director (Asia)
AO Alliance Foundation (AOAF)
Phone +41 81 4130017 | Mobile +977 9851023999
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