SUPPLEMENT ARTICLE

The World Health Organization’s Action Plan on the Road Traffic Injury : Is There Any Action for Orthopaedic Trauma Surgeons?

Paul J. Moroz, MD, MSc, FRCSC* and David A. Spiegel, MD†

recently demonstrated by the Global Burden of Disease Project Summary: Road trafficcrash–related death, injury, and chronic dis- (GBDP)2–4 and a number of publications which have followed, in ability continue to be a major worldwide burden to drivers, pedestrians, particular surgical problems from road trafficcrashes.2–5 The and users of mass transit, especially in low- and middle-income coun- GBDP also introduced the concept of disability-adjusted life tries (LMIC). Projections predict worsening of this burden, and while years (DALYs), a measure of both mortality and disability, and motorization of LMIC increases exponentially, a corresponding estimated that surgically treatableconditionsrepresentedabout improvement in prehospital and acute in-hospital trauma care has not 11% of the world’shealthDALYs,aboutthesamenumberof been seen. The WHO now has 2 programs that address different ele- DALYs contributed by HIV/AIDS, malaria, and ments of this challenge, namely, the Violence and Injury Prevention combined.2–4 Moreover, a number of recent publications have department (prevention) and the Emergency and Essential Surgical suggested that surgical care can be cost effective when delivered Care project (treatment). Activities of Violence and Injury Prevention at the primary referral level in low- and middle-income countries have included developing guidelines for prehospital and essential (LMIC), being as cost effective in terms of dollars spent per trauma care, whereas activities of the Emergency and Essential Surgical saved DALY as HIV or malaria programs.4–6 Of the world’s Care have included developing the Integrated Management of Emer- LMIC, a corresponding increase inavailabilityofadequatepre- gency and Essential Surgical Care toolkit and a textbook, “Surgical hospital and in-hospital trauma care has not been seen and pro- Care at the District Hospital.” Organized surgical institutions in high- jections from the GBDP indicate that road trafficcrasheswill income countries—trauma associations, university departments, surgi- increase in importance over time in the LMIC, where 90% of cal nongovernmental organizations, etc.—can benefitfromtheinfra- road trafficmortalityandmorbidityexists.3 structure and tools the WHO has developed to better address the It is the purpose of this review to outline some of the deficits in surgical services to improve the equitable distribution of WHO’s initiatives developed in response to the LMIC road surgical care services and resources to LMIC. traffic injury pandemic, in particular in the sub-Saharan Key Words: World Health Organization, road traffic crash, action plan African region. (J Orthop Trauma 2014;28:S11–S14) THE BURDEN OF SURGICAL DISEASE Each day on the roads of the world, almost 3500 people die and between 30,000–50,000 are severely injured2,3 with INTRODUCTION many developing long-term musculoskeletal disabilities that Despite almost a decade of existence, many surgeons and drain already poorly resourced health-care systems and surgical institutions [surgical associations, university depart- adversely effect return to work in many already impoverished ments, surgical nongovernmental organizations (NGOs), etc.] societies.3 The GBDP has clearly shown that the majority of may be unaware of the World Health Organization’s (WHO) death and disability from road traffic crashes—85% of deaths commitment to addressing the global burden of surgical dis- and 90% of DALYs—occur in the LMIC of the world, with eases by creating the Emergency and Essential Surgical Care pedestrians, cyclists, and mass transport riders (bus, train) (EESC) program and establishing a global forum called the being a significant portion of this.2–4 The GBDP data also WHO Global Initiative for Emergency and Essential Surgical 1 suggest that deaths, injuries, and disabilities because of road Care (WHO GIEESC). traffic crashes will almost double, from 1.3 million in 2004 to This WHO’ssurgicalinitiativelargelyaroseafterthe 2.4 million in 2030, primarily because of increased motor recognition of the importance of surgical conditions, most vehicle ownership and use associated with economic growth in LMIC.8 To deal with this massive medical and surgical Accepted for publication March 13, 2014. From the *Children’s Hospital of Eastern Ontario, University of Ottawa, burden, the LMIC have access to only 3.5% of the surgical 9 Ottawa, Ontario, Canada; and †Children’s Hospital of Philadelpia, Univer- operative resources available worldwide. sity of Pennsylvania, Philadelphia, PA. Africa faces the highest regional rate of surgical DALYs The authors report no conflict of interest. in the world, led primarily by injuries3,4 which are estimated to Reprints: Paul J. Moroz, MD, MSc, FRCSC, Department of , University fi 3,10 of Ottawa, 401 Smyth Rd, Ottawa, Ontario, K1H8L1 Canada (e-mail: worsen over time largely because of road traf c crashes. [email protected]). Although Africa has one of the lowest rates of registered Copyright © 2014 by Lippincott Williams & Wilkins vehicles per person in the world, the fatality rate from MVC

J Orthop Trauma Volume 28, Number 6 Supplement, June 2014 www.jorthotrauma.com |  S11 Moroz and Spiegel J Orthop Trauma Volume 28, Number 6 Supplement, June 2014  in sub-Saharan Africa significantly exceeds the high-income efforts to research and improve data collection and to dissem- motorized regions of the world.11,12 For each fatality, there inate proven and promising interventions. WHO VIP has also are dozens severely injured and disabled, and to deal with this developed “guidelines for essential trauma care,”26 seeking to carnage, Africa regrettably has among the lowest numbers of set achievable standards for trauma services which could real- trained orthopaedic surgeons in the world.13,14 Most long-term istically be made available to almost every injured person in disabilities are because of injuries of the extremities or the the world. A companion document, prehospital trauma care spine,15,16 with complex long bone injuries among the most systems, attempts to address prehospital trauma care, a signif- disabling of injuries even in advanced trauma systems.17 With icant deficiency in much of the LMIC, and virtually nonex- few surgeons and surgical capacity and with an average per istent in sub-Saharan Africa. The Integrated Management for capita expenditure in most of sub-Saharan Africa being the Emergency and Essential Surgical Care toolkit WHO pro- lowest in the world at $14 per annum, clearly the burden is vides guidance on policies to improve surgical services, significant.18 research, best practices, and Emergency and Trauma Care Training Course modules for frontline health providers.27 THE HISTORY OF SURGERY WITHIN THE WHO Historically, the WHO had expressed a minimalist role THE GLOBAL PLAN FOR THE DECADE OF for surgical interventions in LMIC largely because of the ACTION FOR ROAD SAFETY 2011–2020 perception of an excessively high cost for surgery and a limited With the publication of the World Report on Road ability to realistically offer such “sophisticated” services. Even Traffic Injury Prevention in April 2004,28 the WHO and the basic surgical services were not considered within the realm of World Bank encouraged governments and other stakeholders “primary” care, and as a result, LMIC suffered significant mor- to address and research the problem of road crashes in their tality, morbidity, and disability.4,19,20,21 These previously held regions. The first WHO Global Status Report on Road notions that basic are cost ineffective are now widely Safety,31 published in 2009, summarized data collected from disputed, with many surgical programs having been shown to 178 countries documenting efforts to improve road safety be as cost effective as programs to combat HIV, tuberculosis, records and to provide benchmarks to guide improvements or malaria in LMIC.6,7 This has resulted in a shift in thinking over time. These various initiatives culminated in the March by the WHO in the last decade to include surgery in the public 2010 UN General Assembly’s resolution A/64/255, proclaim- health approach.20 ing 2011–2020 as the Decade of Action for Road Safety, In 2004, in response to deficiencies to deliver even a resolution cosponsored by more than 90 countries. It is basic surgical care to most LMIC, the WHO introduced the meant to help governments, civil society, NGOs, private com- EESC project. Launched to provide a basic surgical training panies, Ministries of Health, academic institutions, and other program to deliver surgical and anesthetic services at the level stakeholders to accelerate the adoption in LMIC of effective of primary care facilities, the program consisted of a teaching and cost-effective road safety programs that have proven use- manual, the “Surgical Care of the District Hospital,”22 and the ful in HIC over the last 50 years. The resolution asked mem- Integrated Management of Emergency and Essential Surgical ber states to implement road safety management, road Care toolkit.23 The toolkit was developed to be adaptable to infrastructure, vehicle safety, road user behavior, road safety local or regional needs and targeted for training nonspecialist education, and efforts in the postcrash response. doctors, nurses, and paramedics, recognizing that for the near Although adopting developed standards for road, future there would not be specialist surgeons at most primary highway infrastructure, and vehicular standards are reason- health-care facilities.7 able goals for Africa on a short-term basis, the development The GIEESC was developed in 2005 to promote the of a surgical service capacity to the level of developed EESC project and to encourage widespread collaboration countries is not realistic on a short-term basis. As a result, the throughout the global surgery community. This is primarily WHO’s mandate for GIEESC is to focus their surgical capac- concerned with surgical training and education and toward ity building at the level of the first referral care, the district strengthening emergency, surgery, and services to hospital. For cultural and other reasons, the majority of the manage injuries, disasters, pregnancy-related surgical com- vulnerable population in sub-Saharan Africa use the district plications, congenital anomalies, and other surgical condi- hospital as opposed to costly large hospitals.4,12 tions at first referral-level health facilities, where 90% of The Decade of Action for Road Safety 2011–2020, LMIC patients go for their care.4 More specifically, GIEESC developed specifically for the African region, the African developed a “situational analysis tool” to survey surgical Road Safety Action Plan 2011–2020, is organized under 5 infrastructure and and man power resources at the “pillars” of development, including (1) road safety manage- primary care hospital level.24 ment; (2) safer roads and mobility; (3) safer vehicles; (4) safer drivers and other road users; and (5) postcrash response— concerning crash-site care, transport, and trauma care of THE RESPONSE OF WHO TO THE ROAD injured, including treatment of disabilities and rehabilitation. TRAFFIC BURDEN It is the fifth pillar of the action plan that pertains most to The WHO Violence and Injury Prevention (WHO VIP) surgeons and where the WHO GIEESC can have an impact in program25 works to prevent injuries and to mitigate disabil- guiding development of an effective prehospital, paramedic, ities from injury by supporting national, regional, and global and emergency medical services in LMIC. Transport of the

S12 | www.jorthotrauma.com Ó 2014 Lippincott Williams & Wilkins J Orthop Trauma Volume 28, Number 6 Supplement, June 2014 WHO’s Action Plan for Road Traffic Crash Pandemic  injured and first responder care continues to be a major bur- Injuries, and Risk Factors in 1990 and Projected to 2020. Cambridge, den in sub-Saharan Africa and will improve with road devel- MA: Harvard University Press; 1996. 3. Murray CJ, Lopez AD. Global mortality, disability, and the contribution of opment but will require surgical input for development, risk factors: global burden of disease study. Lancet. 1997;349:1436–1442. training (ATLS-type programming adapted to local LMIC 4. Debas H, Gosselin R, McCord C, et al. Surgery. In: Jamison DT, country needs), and support of first responders as occurred Breman JG, Measham AR, et al, eds. Disease Control Priorities in in HIC over the last 4 decades. Safer cars and roads, speed Developing Countries. 2nd ed. Available at: http://www.dcp2.org/pubs/ bumps, better lighting, guardrails, etc. will evolve faster in DCP/67/FullText. Accessed June 2, 2013. 5. Gosselin RA, Thind A, Bellardinelli A. Cost/DALY averted in a small Africa if the political will and policing are galvanized. hospital in Sierra Leone: what is the relative contribution of different services? World J Surg. 2006;30:505–511. 6. McCord C, Chowdhury Q. A cost effective small hospital in Bangladesh: THE INPUT OF SURGEONS AND ORGANIZED what it can mean for emergency obstetric care. Int J Gynaecol Obstet. 2003;81:83–92. INSTITUTIONAL SURGERY TO 7. Spiegel DA, Gosselin RA. Surgical services in low-income and middle- WHO’S INITIATIVES income countries. Lancet. 2007;370:1013–1015. Although the response to the global injury burden has 8. Spiegel DA, Abdullah F, Price RR, et al. World Health Organization Global Initiative for Emergency and Essential Surgical Care: 2011 and been one major impetus for WHO GIEESC to develop beyond. World J Surg. 2013;37:1462–1469. surgical capacity, the needs for perinatal and obstetrical 9. Bickler SW, Spiegel D. Improving surgical care in low and middle surgical needs and rehabilitative reconstructive surgery are income countries: a pivotal role for the World Health Organization. also important. For many decades, NGOs, surgical associa- World J Surg. 2010;34:386–390. tions, university departments of surgery, faith-based surgical 10. Mathers CD, Loncar D. Projections of global mortality and burden of disease from 2002 to 2030. PLoS Med. 2006;3:e442. Available at: http:// groups in HIC have helped to provide many surgical services .plosjournals.org/perlserv/?request=get-document&doi=10. 30 to LMIC. Surgery has been recently described as “the ne- 1371/journal.pmed.0030442. Accessed October 19, 2013. glected stepchild of global health,” with equitable distribution 11. Farmer PE, Kim JY. Surgery and global health: a view from beyond the of surgical care in LMIC requiring a greater public health OR. World J Surg. 2008;32:533–536. 9,20 12. Peden M, Kahane T, eds. World Report on Road Traffic Injury Preven- approach, and as such, the WHO can use its infrastructure, tion. Geneva, Switzerland: World Health Organization; 2004. governance capacity, and brand-name influence to partner 13. Kobusingye O, Diallo D, Bartolomeos K, et al. World Health Organiza- with the global surgical community in appropriate collabora- tion Regional Office for Africa. Status Report on Road Safety in Coun- tions to respond to a world where there are inequitably dis- tries of the WHO African Region, 2009. Brazzaville, Congo: World fi tributed surgical resources. Health Organization Regional Of ce for Africa; 2010. 14. Norton R, Kobusingye O. Global health: injuries. N Engl J Med. 2013; Worldwide surveillance and ongoing benchmarking of 368:1723–1730. the surgical burden are essential to monitor the population 15. Bach O. Musculoskeletal trauma in an East African public hospital. health benefits gained with improvements in surgical services. Injury. 2004;35:401–406. Although there is some concern about methodological issues 16. Mock CN, Cherian MN. The global burden of musculoskeletal injuries. with data collection from LMIC on surgical conditions, Clin Orthop Relat Res. 2008;466:2306–2316. 31 17. Mock CN, Boland E, Acheampong F, et al. Long-term injury related improvements in this area are ongoing and self-sustaining disability in Ghana. Disabil Rehabil. 2003;25:732–741. trauma registries have been shown to be effective in low- 18. Masiira-Mukasa N, Ombito BR. Surgical admissions to the Rift resourced environments.32–34 Valley Provincial General Hospital, Kenya. 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Geneva: World Health Organization; 1948. over, will almost certainly be better off when their referring 22. Lett RR, Loutfi A. Essential surgery—respectable again. Can J Surg. district hospitals become more proficient in essential surgical 1995;38:398–399. skills, such as a well-done and definitive first washout of an 23. Bae JY, Groen RS, Kushner AL. Surgery as a public health intervention: 35 common misconceptions versus the truth. Bull World Health Organ. open fracture, and other “damage control” procedures. 2011;89:394. The WHO, through its GIEESC and VIP secretariats, is 24. World Health Organization. Surgical Care at the District Hospital. developing tools, resources, and protocols to help evaluate the Geneva, Switzerland: World Health Organization; 2003. Available at: surgical capacities of district hospitals and clinics in the LMIC. www.who.int/surgery/publications/scdh. Accessed June 14, 2013. 25. World Health Organization. Integrated Management of Emergency and The global surgery community from HIC can use these tools to Essential Surgical Care. World Health Organization. Available at: http:// focus their assistance efforts and expertise in LMIC, and by www.who/int/surgery/publications/imac/en/index.html. Accessed June 14, collaborative partnering, they can benefitfromtheWHO’sglobal 2013. influence to help better address the unmet surgical burdens. 26. WHO situational analysis tool. Available at: www.who.int/entity/ surgery/publication/QucikSitAnalysisEESCsurvey.pdf. Accessed June 14, 2013. REFERENCES 27. WHO violence and injury prevention. Available at: www.who.int/ 1. Available at: www.who.int/surgery. Accessed February 15, 2014. violence_injury_prevention/. Accessed February 14, 2013. 2. Murray CJL, Lopez AD, eds. The Global Burden of Disease: A Com- 28. Available at: http://www.who.int/surgery/publications/imeesc/en/index. prehensive Assessment of Mortality and Disability From Diseases, html.

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