Trauma Care in Africa: The Challenge of Definitive Care

By Michael Emmerich
Published in Ambulance Today, Issue 1, Volume 17, Global Warning & the Burning Issues At The Core Of Prehospital Trauma Care, Spring 2020

This Africa Quarterly explores Trauma Care and, as per usual, we will put the microscope on the African continent in the search for, and the challenge of, definitive care.

Traumatic injuries are a neglected epidemic in developing countries, causing more than five million deaths each year — roughly exceeding the combined deaths from HIV/ AIDS, malaria and tuberculosis.

Due to the unsafe conditions and relatively poor outcomes once someone is injured in low and middle-income countries (LMIC), we found about 90% of the global burden of injury-related mortality and disability to be concentrated within these LMIC countries.

The likelihood of death after injury is up to six-fold greater in an LMIC than in a high-income country! * See figure 1

Around the world, acutely ill and injured people die every day due to a lack of timely emergency care.

Among them are children and adults with injuries and infections, heart attacks and strokes, asthma and acute complications of pregnancy.

Many countries have no emergency access telephone number to call for an ambulance or no trained ambulance staff, or even ambulances / emergency response vehicles.

Many hospitals lack dedicated emergency units and have few providers trained in the recognition and management of emergency conditions. Deaths could be avoided if the necessary structures were in place.

“No one should die for the lack of access to emergency care, an essential part of universal health coverage. We have simple, affordable and proven interventions that save lives. This initiative will ensure that millions of people around the world have access to the timely, life-saving care they deserve.”

—WHO Director-General Dr Tedros Adhanom Ghebreyesus on the launch of the WHO Global Emergency and Trauma Care Initiative, 8th December 2018

But there are winds of change sweeping across the continent, albeit in small pockets and in key isolated areas of the treatment paradigm.

The challenges are huge but, thankfully, the Medical Profession is one of the key, and at times only, driving force behind these changes.

Challenges to trauma care include inadequate pre-hospital and in-hospital trauma care protocols, as well as staff with limited training in trauma management.

Hospitals have no dedicated trauma units, no emergency medical equipment, drugs or trained and skilled physicians / paramedics / nurses to deal with the influx of patients.

In addition to this, poor or absent basic life support training by local communities — or patients and family preferring the services offered by early alternative unconventional traditional care — further hinders definitive trauma care of the sick and injured.

Numerous strategies targeting these challenges are being implemented across the continent driven by a host of NGO’s, Training Institutions, The WHO and other service providers.

Mapping out and, most importantly, adapting mechanisms proven to be effective in developed countries, such as assessment, diagnostic and treatment algorithms (e.g. ATLS and ITLS adapted frameworks), training, prehospital systems, and overall system organization are being driven by medical practitioners across the region.

“Injury is an increasingly significant health problem throughout the world. Every day, 16 000 people die from injuries, and for every person who dies several thousand more are injured — many of them with permanent sequelae. Injury accounts for 16% of the global burden of disease. The burden of death and disability from injury is especially notable in low and middle-income countries. By far the greatest part of the total burden of injury (approximately 90%) occurs in such countries.”

— Etienne Krug, MD, MPH Director, Injuries and Violence Prevention Department WHO

Besides the rapidly rising fatalities, we must also take cognisance of the rising number of injured persons and their cost on the (Global) health burden.

Road-traffic crashes were the number one killer of young people and have accounted for nearly a third of the world injury burden. Most of the victims were young, and many had families that depended on them, who must now rely on other sources of support; in most instances, the State.

Disability after injury is 20–50 times more common than death. Most of the resultant morbidity can be alleviated by early and appropriate rehabilitation services, which many reports/studies and NGO’s list as being sadly lacking.

Rehabilitation is a critical component of the emergency treatment algorithm; without effective rehabilitation we have not maximised the initial effective emergency and surgical care.

The loss of earnings from these deceased or disabled breadwinners is significant. From 2015 to 2030 an estimated US$7.86 trillion is expected to be lost globally due to injuries and LMIC’s are projected to experience losses that are almost 50% greater than high-income countries!

According to the Economist Intelligence Unit Limited 2018, central and southern sub-Saharan Africa is estimated to lose up to 2.5% of GDP to injuries in 2030.

The cost of economic losses from road traffic injuries in LMIC’s are thought to be around the US$100 billion mark per year; the resultant economic burden of injury is higher than that for cancer, diabetes and for respiratory diseases.

The key player in a successful turnaround strategy is not the medical profession, but government. Politicians and State institutions can turn the tide.

True, there are challenges moving forward; many African nations are impoverished and shackled by their burden of external debt, mismanagement of State resources and corruption.

There are also shortages of trained medical professionals and poorly staffed academic institutions, all of which can be redressed by a willing active and engaged government.

Trauma care requires political will and focussed governmental direction on rolling out clear national policies and guidelines.

Where we have seen decreasing mortality rates in LMICs is due to governments recognising the need to roll out coordinated injury development programs, based on clear and strong epidemiologic principles raising awareness with respect to accident prevention; for example, enforcing the wearing of motorcycle helmets.

Thanks to a combination of insufficient, non-existent or poorly enforced safety laws, poor infrastructure and a lack of enforcement alongside a presence of corrupt enforcers, we have countries aiding and abetting in the deaths of over 1.3 million persons annually!

Only 28 countries, representing 449 million people (7% of the world’s population), have adequate laws that address all five risk factors (speed, drunk driving, helmets, seatbelts and child restraints).

Over a third of road traffic deaths in LMICs are among pedestrians and cyclists. However, less than 35% of these countries have policies in place to protect their road users.

Absence of a proactive government has been identified as one of the critical barriers to effective trauma management, due to its influence on all the other essential components of the emergency medical paradigm.

We must work to develop systems that are relevant to Africa and ensure that the “disease” is attacked at all levels: from prevention, to treatment, to rehabilitation.

Without political will, nothing will change; engage politicians and policy makers to ensure injuries are made a national priority and that their allowance is felt as an outrage!

An injury to one is an injury to all — make definitive trauma care a reality!

Additional Reading

Emergency Care in sub-Saharan Africa: Results of a Consensus Conference: pii/S2211419X13000037
At Breaking Point: Understanding the Impact of Musculoskeletal Injuries in Low and Middle-Income Countries: pdf/Injuries-in-LMICs.pdf
Guidelines for Essential Trauma Care: prevention/publications/services/en/ guidelines_traumacare.pdf

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